International Journal of Psychiatry in Clinical Practice, 2008; 12(2): 151155
SHORT REPORT
Gender effect on clinical features and drug treatment response in social anxiety disorder (social phobia)
GABRIELA BEZERRA DE MENEZES1, LEONARDO F. FONTENELLE2 & ´ RCIO VERSIANI2 MA Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
1
Anxiety and Depression Research Program, Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, CEP, Brazil, and 2Department of Psychiatry and Legal Medicine, Federal University of Rio de Janeiro (IPUB/ UFRJ), Anxiety and Depression Research Program
Abstract Objective. To investigate differences concerning clinical and treatment response features in male and female patients with social anxiety disorder (SOAD). Method. Male (n 41) and female patients (n 21) with SOAD were compared with regard to age and mode of onset; SOAD subtype; symptom severity; presence of comorbid psychiatric conditions; and response after drug treatment. The x2-test was used for comparisons between categorical variables and Student’s t-test for continuous variables. The adopted level of statistic significance was 5%. Results. Male patients had a higher mean age (t 2.9; df 42; P 0.006), more severe initial symptoms (t 2.6; df 37.4; P 0.01) and, more often, more than one comorbid psychiatric condition (x2 10.98; df 1; P 0.001). Alcohol abuse was more frequent in men (x2 7.62; df 1; P 0.006). With regard to treatment response, male patients displayed greater reductions in the severity of their baseline symptoms. Patients with SOAD were randomly selected from both samples in order to generate subgroups of 18 male and 18 female age-matched patients. Despite controlling for age, we still found that men exhibited a trend toward greater severity of symptoms at baseline than women with SOAD (t 1.8; df 33.1; P 0.07). Conclusion. The findings suggest differences concerning initial severity and comorbidity rates between men and women suffering from SOAD.
Key Words: Social anxiety disorder, gender, clinical features
Introduction Social anxiety disorder (SOAD) has been associated with one of the highest prevalence rates among psychiatric disorders throughout life and with the highest rate among anxiety disorders. Besides being associated with comorbid psychiatric conditions, SOAD usually results in significant impairment in occupational and social functioning [1]. The lifetime prevalence of SOAD is 13.3%; 15.5% in women and 11.1% in men [2]. In recent years researchers have been paying attention to differences in clinical characteristics of anxiety disorders between genders [35]. Demographic characteristics, comorbid psychiatric conditions, severity and different clinical presentations between men and women could, supposedly, have an influence on the course of the disorder and on the response to treatment. There is little published data regarding gender influence on the presentation of SOAD. It has been
noticed that although women more frequently receive a diagnosis of SOAD in epidemiological studies, men more usually tend to look for treatment, being present in higher or equal rates as women in most clinical samples, unlike that noticed in other anxiety disorders [6,7]. Different social expectations involving men and women may account for different presentations and characteristics of SOAD. It has been suggested that, due to the expectations from the western world, men suffering from SOAD would have higher impairment in the way they socially interact and more difficulty in facing phobic situations [8,9]. The higher social demands on men could mean an extra burden when they suffer from SOAD and explain why they, apparently, seek treatments more frequently. In some studies it has been suggested that men and women would fear specific social situations in a distinct way [9,10]. Considering the scarcity of studies on the subject, we have carried out an investigation about possible
Correspondence: Leonardo F. Fontenelle, Rua Ota´vio Carneiro 93, Apt 601, Icaraı´, Nitero´i, Rio de Janeiro, CEP-24220-071, Brazil. E-mail: lfontenelle@ gmail.com
(Received 26 October 2006; accepted 6 July 2007) ISSN 1365-1501 print/ISSN 1471-1788 online # 2008 Taylor & Francis DOI: 10.1080/13651500701568317
152
G. Bezerra de Menezes et al.
differences in clinical characteristics between men and women suffering from SOAD.
to side effects. At the end of treatment patients were reassessed. Those patients with a final CGI score of 1 (very much improved) or 2 (much improved) were considered responders.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
Materials and methods Patients
Statistical analyses
Sixty-two patients with SOAD, according to DSMIV criteria [11], were included in this study. These patients had spontaneously sought treatment in the Anxiety and Depression Research Program of the Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ). The inclusion/exclusion criteria have been: (1) patients diagnosed with SOAD with or without comorbid psychiatric condition (in the event of comorbidity, patients were included only if they had presented SOAD prior to the comorbid disorder or those in whom SOAD accounted for the more severe and more persistent symptomatology); (2) patients with an age range from 18 to 65 years; (3) patients who did not suffer from neurological disorders. The following clinical variables have been assessed: age at onset of social phobic symptoms (early, 518 years of age, or late, 18 years of age); type of onset (sudden, within days, or insidious); SOAD subtype according to DSM-IV [11] criteria (circumscribed or generalized); severity of symptoms, assessed according to Clinical Global Impression (CGI); and the presence of comorbid psychiatric conditions, according to the Structured Clinical Interview for the Diagnosis of DSM-IV SCID-IV [12]. After the initial assessment, patients were openly treated with different antidepressants (serotonin reuptake inhibitors or tricyclic antidepressants) and/or benzodiazepines, during a period of at least 10 weeks. Doses were administered according to therapeutic response and tolerability
Chi-squared-tests were used to compare categorical variables between both genders. Student’s t-tests were used to compare continuous variables. The adopted level of statistical significance was 5%. Results Of the 62 patients assessed, 41 (66.1%) were male and 21 (33.9%) were female. The age of the patients when the assessment occurred ranged from 19 to 57 years, the mean age being 38.6910.6 years. The onset of the social phobic symptoms was early in 75.8% of the patients and late in 24.2%. The onset was also insidious in most patients (91.9%). Patients with the generalized subtype of SOAD, according to DSM-IV criteria [11], were the majority of the sample (90.3%). Baseline and final severity CGI scores for the total sample were 5.1590.74 and 2.691.5, respectively. At the end of the treatment period, 54.8% of the patients were considered responders (CGI 52). Comorbidity with one, two or three psychiatric disorders were present in 50, 21 and 11.3% of the total sample, respectively. In 82.3% of the total sample there was at least one psychiatric comorbid disorder according to the SCID-IV. The comparison between the socio-demographic, clinical and therapeutic features of men and women with SOAD is depicted in Tables I and II, respectively. Male patients had a higher mean age at assessment (41.3910.6) than female patients
Table I. Comparison of social and demographic features of men and women with SOAD. Male n 41 (66%)
Female n 21 (34%)
41.2910.5
33.499.0
t 2.9; df 42.0; P 0.006*
33 6 1
19 2 0
x2 0.9; df 2; P 0.6
Marital status Single Married Divorced
15 23 3
13 5 3
x2 5.9; df 2; P 0.5
Education Primary Secondary Tertiary
6 14 21
4 12 5
x2 4.4; df 2; P 0.1
Activity Active Inactive
27 13
10 11
x2 2.3; df 1; P 0.1
Age at assessment (years) Race Caucasian Mulatto Black
SOAD, social anxiety disorder. *PB0.05.
Test results
Gender in SOAD
153
Table II. Comparison of clinical and therapeutic features of men and women with SOAD.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
Male n 41 (66%)
Female n 21 (34%)
P
Age of onset Early Late
29 12
18 3
x2 1.7; df 1; P 0.2
Type of onset Sudden Insidious
2 39
3 18
x2 1.6; df 1; P 0.2
SOAD Subtype Circumscribed Generalized
3 38
3 18
x2 0.8; df 1; P 0.4
Number of comorbidities 0 1 2 3
6 16 12 7
5 15 1 0
x2 11.1; df 3; P 0.1
Number of comorbidities 51 1 (multiple comorbidities)
22 19
20 1
x2 10.9; df 1; P 0.001*
Patterns of comorbidity Anxiety disorders Mood disorders Alcohol abuse/dependence
16 29 12
6 11 0
x2 0.6; df 1; P 0.4 x2 2.0; df 1; P 0.1 x2 7.6; df 1; P 0.006*
Initial CGI Initial CGI B5 ]5
5.3290.6 5 36
Final CGI CGI evolution D CGI Rate of response
2.4491.4 2.3391.0 2.991.5 25
4.8190.7 8 13 2.9591.4 1.9390.9 1.991.4 9
t 2.6; df 37.4; P 0.01* x2 5.6; df 1; P 0.02* t 1.2; df 40.0; P 0.2 t 1.5; df 37.5; P 0.1 t 2.6; df 43.2; P 0.013* x2 1.8; df 1; P 0.2
SOAD, social anxiety disorder; CGI, Clinical Global Impression. *P B0.05.
(33.499.0) (t 2.9; df 42.0; P 0.006). Men presented more severe initial symptoms: while their initial mean CGI score was 5.390.7, female patients’ initial mean CGI score was 4.890.7 (t 2.6; df 37.4; P 0.01). [The 49 patients who were classified as severe in the initial assessment (CGI 5 or 6) were mainly men (73.46%) (x2 5.5; df 1; P 0.02).] Since both age at assessment and severity of symptoms were significantly different between men and women with SOAD, we performed an agematched analysis of initial CGI scores. Firstly, we divided our sample into three age bands (1830; 30 45 and 4560). Then, patients with SOAD were randomly selected from both samples in order to generate subgroups of 18 male and 18 female agematched patients. Finally, the subgroups were compared with regard to CGI baseline scores using a t-test. Despite controlling for age, we still found that men exhibited a trend toward greater severity of symptoms at baseline than women with SOAD (t 1.8; df 33.1; P 0.07). There was no statistically significant difference between genders in the rates of specific mood or anxiety disorder. However, men accounted for
95% of the individuals with two or more comorbid psychiatric conditions (x2 11.0; df 1; P 0.001). Moreover, the diagnosis of alcohol addiction/abuse was more frequently found among men (x2 7.6; df 1; P 0.006). When final CGI scores were compared between genders, no statistically significant difference emerged, final CGI among men was 2.491.4 and final CGI among women was 2.991.4. This lack of significant difference was maintained when the rates of male treatment responders (60.9%) were compared to those of female patients (42.8%). However, given that male patients with SOAD exhibited significantly higher CGI scores before treatment, we predicted that these individuals displayed greater improvement in their initial symptoms than female patients. This was confirmed when we compared the difference between the initial and the final CGI scores (the D CGI) between genders (t 2.6; df 43.2; P 0.013). Discussion This study has been an attempt to fill the gap of data relative to the effects of gender on the clinical
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presentation and outcome of social anxiety disorder (SOAD). In our sample, there was a predominance of male patients, similar to what has been described in other clinical samples [6,7]. In epidemiological studies, however, a higher lifetime prevalence rate of social phobia in women has been detected [2]. The higher rates of women versus men in epidemiological samples and the opposite occurring in clinical samples of SOAD may be due to (1) the different degrees of distress and impairment experienced by men and women with the disorder and (2) the different expectations of western society concerning social performance of individuals from different genders. These factors would ultimately lead men to seek treatment more frequently [8]. Among the findings that deserve comments are the older age of men at admission to the study, their higher severity of social phobic symptoms, and their higher frequency of multiple comorbidities (two or more comorbid psychiatric disorders) at the initial assessment. Perhaps it takes a little longer for male patients experiencing social phobia to seek medical treatment, which could account for more severe symptoms and different comorbid psychiatric conditions to develop. Another possibility that can only be fully explored in epidemiological studies would be that SOAD is more severe in men than in women. Prospective follow-up studies could answer the question of whether SOAD evolves more malignly in men. Since both age at assessment and severity of symptoms were significantly different between men and women with SOAD, we performed an analysis of initial CGI scores using 18 male and 18 female agematched patients. Despite controlling for age, the severity of symptoms at baseline remained higher in men with SOAD. Nevertheless, given that this difference was not significant as before, we cannot exclude that age at first assessment may also play a role in the baseline severity of social anxiety symptoms. In spite of the fact that men account for most patients presenting two or more comorbid psychiatric conditions, which had also been noticed in the study carried out by Turk et al. [9], we did not observe differences in comorbidity rates related to anxiety and mood disorders between men and women, different to that observed by Yonkers and colleagues [13]. These latter authors found similar rates of mood disorder between genders but a greater degree of panic disorder with agoraphobia among women with SOAD. Once anxiety and mood disorders are more common among women in general, the absence of such a difference in our clinical sample suggests that men undergoing treatment for social phobia may present higher rates of such disorders. Perhaps comorbidity associated to depression or higher levels of anxiety pushes men suffering from social phobia to search for treatment.
We have also observed that the diagnosis of alcohol addiction/abuse was more frequently found among men, similar to the results observed by Yonkers and colleagues [13]. It is not possible, however, to ascribe a higher risk of development of alcohol addiction/abuse to male patients suffering from social phobia given that men more frequently abuse or have problems concerning alcohol addiction, even in epidemiological studies. Although there are many studies associating alcohol addiction with SOAD, few data are available with regard to gender. Randall et al. [14] compared men and women with concomitant alcohol abuse and social phobia enrolled in an alcohol treatment study, and they did not observe significant gender differences on demographic features. They described, however, significantly higher rates of comorbid mood disorder among women. In our study, no difference concerning the treatment outcome was found when both genders were compared in terms of their CGI scores at the endpoint, which is a similar result to that described by Reich et al. [15] who do not regard gender as a variable capable of predicting the course of the disorder. However, when the magnitude of the reduction of symptoms (the CGI scores at the baseline minus the CGI scores at the end-point) was compared between the two groups, we found that male patients with SOAD displayed significantly greater reductions in the severity of their symptoms. In other words, despite exhibiting a more severe clinical picture, male patients with SOAD may be more responsive to treatment. Admittedly, our paper has a number of drawbacks, including the small sample size; the restricted, nonblinded clinical assessment (which only included the CGI); the absence of treatment randomization; and the lack of corrections for multiple comparisons. Therefore, the preliminary nature of our findings needs to be taken into consideration. Future studies, with greater numbers of patients and more sophisticated methods of evaluation, should investigate the role of potential confounding factors, such as alcohol abuse and treatment-seeking bias, on the clinical expression and treatment outcome of gender-related SOAD. Key points . From the socio-demographic point-of-view, male patients with social phobia are characterized by a higher mean age at presentation for treatment than female patients . In terms of clinical features, male patients with social phobia display more severe initial symptoms, multiple psychiatric comorbidities, and alcohol abuse significantly more often than female patients
Gender in SOAD . With regard to treatment response, male patients with social phobia displayed greater reductions in the severity of their symptoms than female patients
[7] Lang AJ, Stein MB. Social Phobia: Prevalence and diagnostic threshold. J Clin Psychiatry 2001;62(Suppl 1):510. [8] Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry 1999;60(Suppl 9):913. [9] Turk CL, Heimberg RG, Orsillo SM, et al. An investigational of gender differences in social phobia. J Anxiety Disord 1998;12:20923. [10] Grossman P, Wilhem FH, Kawachi I, Sparrow D. Gender differences in psychophisiological responses to speech stress among older social phobics: congruence and incongruence between self-evaluative and cardiovascular reactions. Psychosom Med 2001;63:76577. [11] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. [12] First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Patient Edition (SCID-I/P). New York: Biometrics Research, New York State Psychiatric Institute; 1997. [13] Yonkers KA, Dyck IR, Keller MB. An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women. Psychiatr Serv 2002; 52:63743. [14] Randall CL, Thomas SE, Thevos AK. Gender comparison in alcoholics with concurrent social phobia: Implications for alcoholism treatment. Am J Addict 2000;9:20215. [15] Reich J, Goldenberg I, Goisman R, Vasile R, Keller M. A prospective, follow-along study of the course of social phobia: II. Testing for basic predictors of course. J Nerv Ment Dis 1994;182:297301. /
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Statement of interest
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The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.
[1] Moutier CY, Stein MB. The history, epidemiology, and differential diagnosis of social anxiety disorder. J Clin Psychiatry 1999;60(Suppl 9):48. [2] Kessler RC, Mcgonagle KA, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:819. [3] Bekker MHJ. Agoraphobia and gender: A review. Clin Psychol Rev 1996;16:12946. [4] Fontenelle L, Marques C, Versiani M. The effect of gender on the clinical features and therapeutic response in obsessivecompulsive disorder. Rev Bras Psiquiatr 2002;24:711. [5] Oei TPS, Wanstall K, Evans L. Sex differences in panic disorder with agoraphobia. J Anxiety Disord 1990;4:31724. [6] Stein MB. Phenomenology and epidemiology of social phobia. Int Clin Psychopharmacol 1997;12(Suppl 6): S236.
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SHORT REPORT
Gender effect on clinical features and drug treatment response in social anxiety disorder (social phobia)
GABRIELA BEZERRA DE MENEZES1, LEONARDO F. FONTENELLE2 & ´ RCIO VERSIANI2 MA Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
1
Anxiety and Depression Research Program, Institute of Psychiatry of the Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, CEP, Brazil, and 2Department of Psychiatry and Legal Medicine, Federal University of Rio de Janeiro (IPUB/ UFRJ), Anxiety and Depression Research Program
Abstract Objective. To investigate differences concerning clinical and treatment response features in male and female patients with social anxiety disorder (SOAD). Method. Male (n 41) and female patients (n 21) with SOAD were compared with regard to age and mode of onset; SOAD subtype; symptom severity; presence of comorbid psychiatric conditions; and response after drug treatment. The x2-test was used for comparisons between categorical variables and Student’s t-test for continuous variables. The adopted level of statistic significance was 5%. Results. Male patients had a higher mean age (t 2.9; df 42; P 0.006), more severe initial symptoms (t 2.6; df 37.4; P 0.01) and, more often, more than one comorbid psychiatric condition (x2 10.98; df 1; P 0.001). Alcohol abuse was more frequent in men (x2 7.62; df 1; P 0.006). With regard to treatment response, male patients displayed greater reductions in the severity of their baseline symptoms. Patients with SOAD were randomly selected from both samples in order to generate subgroups of 18 male and 18 female age-matched patients. Despite controlling for age, we still found that men exhibited a trend toward greater severity of symptoms at baseline than women with SOAD (t 1.8; df 33.1; P 0.07). Conclusion. The findings suggest differences concerning initial severity and comorbidity rates between men and women suffering from SOAD.
Key Words: Social anxiety disorder, gender, clinical features
Introduction Social anxiety disorder (SOAD) has been associated with one of the highest prevalence rates among psychiatric disorders throughout life and with the highest rate among anxiety disorders. Besides being associated with comorbid psychiatric conditions, SOAD usually results in significant impairment in occupational and social functioning [1]. The lifetime prevalence of SOAD is 13.3%; 15.5% in women and 11.1% in men [2]. In recent years researchers have been paying attention to differences in clinical characteristics of anxiety disorders between genders [35]. Demographic characteristics, comorbid psychiatric conditions, severity and different clinical presentations between men and women could, supposedly, have an influence on the course of the disorder and on the response to treatment. There is little published data regarding gender influence on the presentation of SOAD. It has been
noticed that although women more frequently receive a diagnosis of SOAD in epidemiological studies, men more usually tend to look for treatment, being present in higher or equal rates as women in most clinical samples, unlike that noticed in other anxiety disorders [6,7]. Different social expectations involving men and women may account for different presentations and characteristics of SOAD. It has been suggested that, due to the expectations from the western world, men suffering from SOAD would have higher impairment in the way they socially interact and more difficulty in facing phobic situations [8,9]. The higher social demands on men could mean an extra burden when they suffer from SOAD and explain why they, apparently, seek treatments more frequently. In some studies it has been suggested that men and women would fear specific social situations in a distinct way [9,10]. Considering the scarcity of studies on the subject, we have carried out an investigation about possible
Correspondence: Leonardo F. Fontenelle, Rua Ota´vio Carneiro 93, Apt 601, Icaraı´, Nitero´i, Rio de Janeiro, CEP-24220-071, Brazil. E-mail: lfontenelle@ gmail.com
(Received 26 October 2006; accepted 6 July 2007) ISSN 1365-1501 print/ISSN 1471-1788 online # 2008 Taylor & Francis DOI: 10.1080/13651500701568317
152
G. Bezerra de Menezes et al.
differences in clinical characteristics between men and women suffering from SOAD.
to side effects. At the end of treatment patients were reassessed. Those patients with a final CGI score of 1 (very much improved) or 2 (much improved) were considered responders.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
Materials and methods Patients
Statistical analyses
Sixty-two patients with SOAD, according to DSMIV criteria [11], were included in this study. These patients had spontaneously sought treatment in the Anxiety and Depression Research Program of the Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ). The inclusion/exclusion criteria have been: (1) patients diagnosed with SOAD with or without comorbid psychiatric condition (in the event of comorbidity, patients were included only if they had presented SOAD prior to the comorbid disorder or those in whom SOAD accounted for the more severe and more persistent symptomatology); (2) patients with an age range from 18 to 65 years; (3) patients who did not suffer from neurological disorders. The following clinical variables have been assessed: age at onset of social phobic symptoms (early, 518 years of age, or late, 18 years of age); type of onset (sudden, within days, or insidious); SOAD subtype according to DSM-IV [11] criteria (circumscribed or generalized); severity of symptoms, assessed according to Clinical Global Impression (CGI); and the presence of comorbid psychiatric conditions, according to the Structured Clinical Interview for the Diagnosis of DSM-IV SCID-IV [12]. After the initial assessment, patients were openly treated with different antidepressants (serotonin reuptake inhibitors or tricyclic antidepressants) and/or benzodiazepines, during a period of at least 10 weeks. Doses were administered according to therapeutic response and tolerability
Chi-squared-tests were used to compare categorical variables between both genders. Student’s t-tests were used to compare continuous variables. The adopted level of statistical significance was 5%. Results Of the 62 patients assessed, 41 (66.1%) were male and 21 (33.9%) were female. The age of the patients when the assessment occurred ranged from 19 to 57 years, the mean age being 38.6910.6 years. The onset of the social phobic symptoms was early in 75.8% of the patients and late in 24.2%. The onset was also insidious in most patients (91.9%). Patients with the generalized subtype of SOAD, according to DSM-IV criteria [11], were the majority of the sample (90.3%). Baseline and final severity CGI scores for the total sample were 5.1590.74 and 2.691.5, respectively. At the end of the treatment period, 54.8% of the patients were considered responders (CGI 52). Comorbidity with one, two or three psychiatric disorders were present in 50, 21 and 11.3% of the total sample, respectively. In 82.3% of the total sample there was at least one psychiatric comorbid disorder according to the SCID-IV. The comparison between the socio-demographic, clinical and therapeutic features of men and women with SOAD is depicted in Tables I and II, respectively. Male patients had a higher mean age at assessment (41.3910.6) than female patients
Table I. Comparison of social and demographic features of men and women with SOAD. Male n 41 (66%)
Female n 21 (34%)
41.2910.5
33.499.0
t 2.9; df 42.0; P 0.006*
33 6 1
19 2 0
x2 0.9; df 2; P 0.6
Marital status Single Married Divorced
15 23 3
13 5 3
x2 5.9; df 2; P 0.5
Education Primary Secondary Tertiary
6 14 21
4 12 5
x2 4.4; df 2; P 0.1
Activity Active Inactive
27 13
10 11
x2 2.3; df 1; P 0.1
Age at assessment (years) Race Caucasian Mulatto Black
SOAD, social anxiety disorder. *PB0.05.
Test results
Gender in SOAD
153
Table II. Comparison of clinical and therapeutic features of men and women with SOAD.
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
Male n 41 (66%)
Female n 21 (34%)
P
Age of onset Early Late
29 12
18 3
x2 1.7; df 1; P 0.2
Type of onset Sudden Insidious
2 39
3 18
x2 1.6; df 1; P 0.2
SOAD Subtype Circumscribed Generalized
3 38
3 18
x2 0.8; df 1; P 0.4
Number of comorbidities 0 1 2 3
6 16 12 7
5 15 1 0
x2 11.1; df 3; P 0.1
Number of comorbidities 51 1 (multiple comorbidities)
22 19
20 1
x2 10.9; df 1; P 0.001*
Patterns of comorbidity Anxiety disorders Mood disorders Alcohol abuse/dependence
16 29 12
6 11 0
x2 0.6; df 1; P 0.4 x2 2.0; df 1; P 0.1 x2 7.6; df 1; P 0.006*
Initial CGI Initial CGI B5 ]5
5.3290.6 5 36
Final CGI CGI evolution D CGI Rate of response
2.4491.4 2.3391.0 2.991.5 25
4.8190.7 8 13 2.9591.4 1.9390.9 1.991.4 9
t 2.6; df 37.4; P 0.01* x2 5.6; df 1; P 0.02* t 1.2; df 40.0; P 0.2 t 1.5; df 37.5; P 0.1 t 2.6; df 43.2; P 0.013* x2 1.8; df 1; P 0.2
SOAD, social anxiety disorder; CGI, Clinical Global Impression. *P B0.05.
(33.499.0) (t 2.9; df 42.0; P 0.006). Men presented more severe initial symptoms: while their initial mean CGI score was 5.390.7, female patients’ initial mean CGI score was 4.890.7 (t 2.6; df 37.4; P 0.01). [The 49 patients who were classified as severe in the initial assessment (CGI 5 or 6) were mainly men (73.46%) (x2 5.5; df 1; P 0.02).] Since both age at assessment and severity of symptoms were significantly different between men and women with SOAD, we performed an agematched analysis of initial CGI scores. Firstly, we divided our sample into three age bands (1830; 30 45 and 4560). Then, patients with SOAD were randomly selected from both samples in order to generate subgroups of 18 male and 18 female agematched patients. Finally, the subgroups were compared with regard to CGI baseline scores using a t-test. Despite controlling for age, we still found that men exhibited a trend toward greater severity of symptoms at baseline than women with SOAD (t 1.8; df 33.1; P 0.07). There was no statistically significant difference between genders in the rates of specific mood or anxiety disorder. However, men accounted for
95% of the individuals with two or more comorbid psychiatric conditions (x2 11.0; df 1; P 0.001). Moreover, the diagnosis of alcohol addiction/abuse was more frequently found among men (x2 7.6; df 1; P 0.006). When final CGI scores were compared between genders, no statistically significant difference emerged, final CGI among men was 2.491.4 and final CGI among women was 2.991.4. This lack of significant difference was maintained when the rates of male treatment responders (60.9%) were compared to those of female patients (42.8%). However, given that male patients with SOAD exhibited significantly higher CGI scores before treatment, we predicted that these individuals displayed greater improvement in their initial symptoms than female patients. This was confirmed when we compared the difference between the initial and the final CGI scores (the D CGI) between genders (t 2.6; df 43.2; P 0.013). Discussion This study has been an attempt to fill the gap of data relative to the effects of gender on the clinical
Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Waterloo on 10/27/14 For personal use only.
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presentation and outcome of social anxiety disorder (SOAD). In our sample, there was a predominance of male patients, similar to what has been described in other clinical samples [6,7]. In epidemiological studies, however, a higher lifetime prevalence rate of social phobia in women has been detected [2]. The higher rates of women versus men in epidemiological samples and the opposite occurring in clinical samples of SOAD may be due to (1) the different degrees of distress and impairment experienced by men and women with the disorder and (2) the different expectations of western society concerning social performance of individuals from different genders. These factors would ultimately lead men to seek treatment more frequently [8]. Among the findings that deserve comments are the older age of men at admission to the study, their higher severity of social phobic symptoms, and their higher frequency of multiple comorbidities (two or more comorbid psychiatric disorders) at the initial assessment. Perhaps it takes a little longer for male patients experiencing social phobia to seek medical treatment, which could account for more severe symptoms and different comorbid psychiatric conditions to develop. Another possibility that can only be fully explored in epidemiological studies would be that SOAD is more severe in men than in women. Prospective follow-up studies could answer the question of whether SOAD evolves more malignly in men. Since both age at assessment and severity of symptoms were significantly different between men and women with SOAD, we performed an analysis of initial CGI scores using 18 male and 18 female agematched patients. Despite controlling for age, the severity of symptoms at baseline remained higher in men with SOAD. Nevertheless, given that this difference was not significant as before, we cannot exclude that age at first assessment may also play a role in the baseline severity of social anxiety symptoms. In spite of the fact that men account for most patients presenting two or more comorbid psychiatric conditions, which had also been noticed in the study carried out by Turk et al. [9], we did not observe differences in comorbidity rates related to anxiety and mood disorders between men and women, different to that observed by Yonkers and colleagues [13]. These latter authors found similar rates of mood disorder between genders but a greater degree of panic disorder with agoraphobia among women with SOAD. Once anxiety and mood disorders are more common among women in general, the absence of such a difference in our clinical sample suggests that men undergoing treatment for social phobia may present higher rates of such disorders. Perhaps comorbidity associated to depression or higher levels of anxiety pushes men suffering from social phobia to search for treatment.
We have also observed that the diagnosis of alcohol addiction/abuse was more frequently found among men, similar to the results observed by Yonkers and colleagues [13]. It is not possible, however, to ascribe a higher risk of development of alcohol addiction/abuse to male patients suffering from social phobia given that men more frequently abuse or have problems concerning alcohol addiction, even in epidemiological studies. Although there are many studies associating alcohol addiction with SOAD, few data are available with regard to gender. Randall et al. [14] compared men and women with concomitant alcohol abuse and social phobia enrolled in an alcohol treatment study, and they did not observe significant gender differences on demographic features. They described, however, significantly higher rates of comorbid mood disorder among women. In our study, no difference concerning the treatment outcome was found when both genders were compared in terms of their CGI scores at the endpoint, which is a similar result to that described by Reich et al. [15] who do not regard gender as a variable capable of predicting the course of the disorder. However, when the magnitude of the reduction of symptoms (the CGI scores at the baseline minus the CGI scores at the end-point) was compared between the two groups, we found that male patients with SOAD displayed significantly greater reductions in the severity of their symptoms. In other words, despite exhibiting a more severe clinical picture, male patients with SOAD may be more responsive to treatment. Admittedly, our paper has a number of drawbacks, including the small sample size; the restricted, nonblinded clinical assessment (which only included the CGI); the absence of treatment randomization; and the lack of corrections for multiple comparisons. Therefore, the preliminary nature of our findings needs to be taken into consideration. Future studies, with greater numbers of patients and more sophisticated methods of evaluation, should investigate the role of potential confounding factors, such as alcohol abuse and treatment-seeking bias, on the clinical expression and treatment outcome of gender-related SOAD. Key points . From the socio-demographic point-of-view, male patients with social phobia are characterized by a higher mean age at presentation for treatment than female patients . In terms of clinical features, male patients with social phobia display more severe initial symptoms, multiple psychiatric comorbidities, and alcohol abuse significantly more often than female patients
Gender in SOAD . With regard to treatment response, male patients with social phobia displayed greater reductions in the severity of their symptoms than female patients
[7] Lang AJ, Stein MB. Social Phobia: Prevalence and diagnostic threshold. J Clin Psychiatry 2001;62(Suppl 1):510. [8] Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry 1999;60(Suppl 9):913. [9] Turk CL, Heimberg RG, Orsillo SM, et al. An investigational of gender differences in social phobia. J Anxiety Disord 1998;12:20923. [10] Grossman P, Wilhem FH, Kawachi I, Sparrow D. Gender differences in psychophisiological responses to speech stress among older social phobics: congruence and incongruence between self-evaluative and cardiovascular reactions. Psychosom Med 2001;63:76577. [11] American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994. [12] First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version, Patient Edition (SCID-I/P). New York: Biometrics Research, New York State Psychiatric Institute; 1997. [13] Yonkers KA, Dyck IR, Keller MB. An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women. Psychiatr Serv 2002; 52:63743. [14] Randall CL, Thomas SE, Thevos AK. Gender comparison in alcoholics with concurrent social phobia: Implications for alcoholism treatment. Am J Addict 2000;9:20215. [15] Reich J, Goldenberg I, Goisman R, Vasile R, Keller M. A prospective, follow-along study of the course of social phobia: II. Testing for basic predictors of course. J Nerv Ment Dis 1994;182:297301. /
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Statement of interest
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The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.
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