344 TREATMENT OF SPECIFIC ANXIETY DISORDERS
thereby compounding the problem of low service utilization (Wagner, Silvoe, Marnane,
& Rouen, 2006). In fact analysis of the NCS-R data set also confirms that the disorder
is undertreated, with some evidence that those who have the greatest need for treatment
are least likely to receive it (Ruscio, Brown, et al., 2007).
Clinician Guideline 9.4
Social phobia is the most prevalent of the anxiety disorders, affecting slightly more women
than men, with cultural differences in rate and clinical presentation. The disorder com-
monly arises in late childhood or adolescence and takes a chronic and unremitting course
that results in significant decrement in social and occupational functioning. Despite these
negative effects, individuals typically delay seeking treatment.Comorbidity
Social phobia can be difficult to distinguish from other anxiety disorders because social
anxiety is a common symptom in all the anxiety disorders and comobidity rates are high
in those with a principal diagnosis of social phobia (Turner & Beidel, 1989). Rapee et
al. (1988) found that 80% of individuals with panic disorder, GAD, or simple phobia
reported at least slight fear in one or more social situations and over 50% reported mod-
erate fear and avoidance. At the same time, rates of more serious secondary social phobia
that meet diagnostic criteria are high among those with another primary anxiety disor-
der or major depression. In the large clinical study by Brown et al. (2001), secondary
social phobia was present in large numbers of patients with panic disorder (23%), GAD
(42%), OCD (35%), specific phobia (27%), PTSD (41%), and major depression (43%).
The comorbidity rate for those with a principal diagnosis of social phobia appears
similar to the overall rates found in the other anxiety disorders. Lifetime rates of comor-
bid disorder range from 69 to 88% (Brown et al., 2001; Kessler, Berglund, et al., 2005;
Schneier et al., 1992; Wittchen et al., 1999), with approximately three- quarters of indi-
viduals with social phobia currently meeting criteria for another major disorder. In
most cases social phobia precedes onset of the other disorder (e.g., Brown et al., 2001;
Schneier et al., 1992) and is associated with greater functional impairment than uncom-
plicated cases of social phobia (Wittchen et al., 1999).
The highest rates of comorbid conditions in social phobia are major depression,
substance abuse, GAD, and, to a lesser extent, panic disorder. In the NCS, 56.9% of
individuals with social phobia had a comorbid anxiety disorder, the most common
being simple phobia (37.6%), agoraphobia (23.2%), and GAD (13.3%) (Magee et al.,
1996). Major depression occurred in 37.2% and substance abuse in 39.6% of social
phobia cases. In the NCS-R social phobia correlated most highly with GAD, PTSD,
major depression, attention- deficit/hyperactivity disorder, and drug dependence (Kes-
sler, Chiu, et al., 2005).
One might expect high rates of alcohol consumption in social phobia as a form of
self- medication (Rapee, 1995b), but findings from the epidemiological studies suggest
the rates of comorbid substance disorder are no greater in social phobia than in the
other anxiety disorders or major depression (Grant et al., 2004). However, in a recent
review Morris, Stewart, and Ham (2005) concluded that individuals with generalized