Editorial

Social phobia in late-life: is it wortha diagnosis?

Despite their high prevalence in older people,anxiety disorders have received scant researchattention compared to other common conditionssuch as depression and dementia. Social phobia isknown to be disabling at any age but is likely to beparticularly important in late-life because of therecognised associations between social supportdeficits and many adverse outcomes, includingdepression (1), dementia (2, 3) and physical disor-ders such as coronary heart disease (4, 5) and somevascular risk factors (6, 7), as well as enhancing theassociation between depression and mortality (8).Clearly a person�s level of social contact is amixture of their own preference and environmentalimposition. As a source of stress, it is most likelythat adverse consequences are highest for peoplewhose social networks are limited against theirwishes (for example, through bereavement orlimitations imposed by health conditions) ratherthan those who have always preferred a moresolitary existence. Social phobia can be consideredas representing an extreme form of the formerscenario and, as such, should be taken just asseriously in older compared to younger people, ifnot more so. The study by Karlsson et al. (9) inthis issue is therefore welcome because it providesnovel and important information on the temporalstability of the condition in older people both interms of �new� cases arising and of �recovery� inprevious cases.As with most affective disorders, the observed

prevalence of social phobia at a given time pointdepends substantially on the instrument and crite-ria used to define it. Estimates for the prevalence ofanxiety disorders in older people have ranged from1.2% using the GMS-AGECAT diagnostic inter-view (10) to 14% using DSM-IV criteria (11), whileprevalence estimates for any phobic disorder insimilar age groups have ranged from 1.4% usingthe GMS-AGECAT (10) to 25.6% using thePhobic Disorders Screen (12). Previously reportedcross-sectional data from the Swedish cohort forwhich prospective data are described here indicateda one month period prevalence of 1.6% for socialphobia if strict DSM-IV criteria were applied (13).

While this figure cannot be generalised to otherolder populations because of the nature of thesample (consisting of 70 year old men and women,and 78 year old women), what was important wasthat the observed prevalence increased almost two-fold (to 3.5%) if the specific DSM-IV requirementwas dropped for �experiencing the fear as unrea-sonable or excessive� – i.e. all participants definedin this broader manner still described a fear of asocial situation, an avoidance of the feared socialsituation (or an endurance of it with intenseanxiety and distress), and adverse social conse-quences arising as a result (14). Over-rigorousapplication of diagnostic criteria may therefore bemisleading and, indeed, could be construed as�ageist� if they are allowed to support potentiallyfalse inferences concerning differences in preva-lence between age groups which may simply havearisen because older people report a given syn-drome in a different manner. If an older personreports a disabling social fear resulting in avoid-ance of the feared situation, is it reasonable to saythat they do not have a phobic disorder (andtherefore under-estimate prevalence) if they fail toreport the fear as being unreasonable or excessive,perhaps because of a higher level of stoicism (orreluctance to report something as problematic)? Onthe other hand, research criteria for mental disor-ders traditionally include some prerequisite effecton function, and it is important to bear in mindthat the threshold at which a given level ofsymptomatology affects daily activities may bedetermined by other contextual factors. An olderperson might therefore be more likely to reportfunctional impairment relating to phobic symp-toms (i.e. resulting in an over-estimated preva-lence) if that function has already beencompromised because of physical health worries(e.g. fear of incontinence) or other mental disorders(e.g. mild cognitive impairment).Clearly, the problem here relates to the under-

lying semantics and applicability of standarddiagnostic criteria. Researchers should constantlybear in mind that traditional �diagnoses� are simplyconstructs applied to help a clinician communicate

Acta Psychiatr Scand 2010: 122: 1–3All rights reservedDOI: 10.1111/j.1600-0447.2010.01575.x

� 2010 John Wiley & Sons A/S

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with a consulting patient, and that �researchdiagnostic criteria� exist to standardise the way inwhich these constructs are elicited (i.e. theirreliability), but that achieving good reliabilitydoes not mean that the constructs necessarilyhave validity (i.e. may not reflect the underlyingreality of mental ill-health). A commendable fea-ture of the paper by Karlsson et al.(9) is that ittakes a flexible approach to the issue of �diagnosis�applied in social phobia; in particular, that theanalyses apply both the strict DSM-IV criteria andthe more loose but probably more clinically real-istic definition (labelled here �clinical socialphobia�) as well as other sub-clinical and symp-tomatic categories.The most striking finding from this naturalistic

study is that only around a quarter of participantswith clinical social phobia at baseline were definedas having this condition 5 years later, and close toone half did not describe any social anxiety at all atfollow-up. These proportions were not changedsubstantially if the baseline �diagnosis� wasrestricted to full DSM-IV criteria. Social phobiadefined in a community population thereforeappears to be a much less stable construct thanthe chronic condition which has been inferred fromprospective clinical research (15). While no dataare displayed on treatment received, it is unlikelythat the high �recovery� rate is accounted for bymedical or psychological interventions, as commonmental disorders are generally poorly recognised ortreated in community samples and the report doesstate that receipt or not of antidepressants atbaseline or follow-up was not associated withprognosis in the sample. Spontaneous recoverytherefore appears to be the norm for social phobia,and clinicians working with older people, as well aspeople affected, can surely take heart from this,although as the authors warn, we need to bear inmind that social phobia seen in secondary ortertiary care settings may contain more severe orintractable syndromes than screened cases in com-munity samples.The authors go on to describe the five-year

�incidence� of social phobia (i.e. the proportionfulfilling criteria at follow-up who did not do so atbaseline), and describe proportions ranging from2.0% for DSM-IV social phobia through 4.2% forclinical social phobia, to 16.6% for any social fear.This illustrates the point where traditional con-structs applied in epidemiological research begin tofail in the face of conditions for which they are notsuited. �Incidence� of course is typically, and mostusefully, applied to an event whose occurrence canbe accurately ascertained and located in time (forexample, a myocardial infarction or stroke) or to a

change of state from health to ill-health where thechange is relatively abrupt and where spontaneousrecovery from the state of ill-health is unlikely (forexample, cancer or diabetes). Mental disorders donot readily fit either of these patterns, eitherbecause they develop insidiously (for example,dementia and many cases of psychotic disorder inearly adult life) or because they fluctuate inintensity between case ⁄non-case levels. Affectivedisorders typically follow the latter pattern andpresent a substantial challenge for researchers whowish to communicate something about theircourse. Is 5-year incidence a helpful construct fora disorder such as social phobia where only aquarter will continue to experience the disorderafter a further 5 years?This problem is accentuated in late adult life

because of the greater length of preceding timeover which such a fluctuation may have occurred.Most community studies of common mental dis-orders in older people have relied on 2-wave panelsurvey designs, similar to the analysis reportedhere. Disorder �incidence� or �onset� tends to referto its absence at time 1 and presence at time 2. The�incident� cases include both those who are expe-riencing their first ever episode at time 2 and thosewho have had chronic ill-health over a much longerperiod, perhaps even over most of their life, butwhose symptomatology happened to be belowcase-level at time 1. The non-incident cases includethose who remained free of symptoms throughoutthe follow-up period, those who remained at sub-case levels during that period and those whoexperienced a case-level episode which had fallenbelow case-level criteria before the time 2 exami-nation. Clearly all of these groups represent verydifferent levels of mental ill-health; however, theyare poorly characterised by the �incidence� para-digm. The �recovery� paradigm can be criticised in asimilar manner, there being a variety of patterns ofchange from an initial case-level state, although 2-phase studies do more readily convey clinicallyuseful information, for example, in the case of thestudy by Karlsson et al. (9)., being able to tellsomeone with social phobia that, regardless oftreatment, they have a nearly 50% chance of nothaving any social anxiety within 5 years time(although clearly information on shorter-termprognosis would also be helpful).What are the potential solutions? The use of

multiple diagnostic �levels� is a helpful start, asmentioned earlier. However, it is clear that mentalhealth research may have to move beyond �tradi-tional epidemiology� and forge ahead with newways of classifying patterns of transitions betweenhealth and ill-health over time, just as it has led the

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way in the field of psychometrics by necessitybecause of the lack of biological measurements andthe reliance on accessing individuals� subjectiveexperiences for standard diagnostic constructs.Psychometrics as a field has made substantialadvances in characterising states of health at asingle point in time, and perhaps a new disciplineof �prospective psychometrics� is required to quan-tify the complex ways in which mental health statescan fluctuate over weeks, months or years. Rea-sonable progress has been made in describing theclinical course of conditions which have reachedsufficient severity to present to secondary careservices (16), as well as some naturalistic researchin screened community samples (17), although eventhese involve relatively crude categorisation ofdifferent course patterns which do not move veryfar beyond the �rule of thirds� beloved of medicalstudents for describing outcomes for most chronicconditions. Characterisation of longer-term courseis more challenging and will involve a movebeyond simple two-phase designs with shorterintervals between multiple examinations to plotsymptom changes more accurately, as well astransitions between states with differing symptompredominance (e.g. between generalised anxietyand depressive syndromes). A certain amount ofretrospective recall is likely to be necessary iffluctuations between examinations are to be quan-tified. However, attempts to define �lifetime� disor-ders in older people are likely to prove moreproblematic given evidence that even major depres-sive episodes are very poorly recalled 25 years later(18). Finally, just as the field of �cross-sectionalpsychometrics� has provided the mathematicalmodels for quantifying symptom clustering andunderlying dimensions, so �prospective psychomet-rics� needs the further development of mathemat-ical models which take the field beyond simple�incidence� and �maintenance� categorisation.

Robert Stewart and James LindesayActa Psychiatrica Scandinavica

Invited Guest Editors

References

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AM, Davidson IA. Is there more dementia, depression andneurosis in New York? A comparative study of the elderlyin New York and London using the computer diagnosisAGECAT Br J Psychiat 1987;151:466–473.

11. Ritchie K, Artero S, Beluche I. Prevalence of DSM-IVdisorder in the French elderly population. Br J Psychiat2004;184:147–152.

12. Lindesay J, Banerjee S. Phobic disorder in the elderly: acomparison of three diagnostic systems. Int J GeriatrPsychiatry 1993;8:387–393.

13. Karlsson B, Klenfeldt IF, Sigstrom R et al. Prevalence ofsocial phobia in non-demented elderly from a swedishpopulation study. Am J Psychiat 2010;17:127–135.

14. American Psychiatric Association. Diagnostic and Statis-tical Manual of Mental Disorders, Fourth Edition.Washington, D.C.: APA, 1994.

15. Bruce SE, Yonkers KA, Otto MW et al. Influence of psy-chiatric comorbidity on recovery and recurrence in gener-alized anxiety disorder, social phobia, and panic disorder:a 12-year prospective study. Am J Psychiat 2005;162:1179–1187.

16. Trivedi MH, Rush AJ, Wisniewski SR et al. Evaluation ofoutcomes with citalopram for depression using measure-ment-based care in STAR*D: implications for clinicalpractice. Am J Psychiat 2006;163:28–40.

17. Beekman ATF, Geerlings SW, Deeg DJH et al. The naturalhistory of late-life depression. A 6-year prospective studyin the community. Arch Gen Psychiatry 2002;59:605–611.

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