Les phobies sociales en psychiatrie : caractéristiques cliniques et modalités de prise en charge (étude Phœnix)

Only few clinical epidemiologic studies have been conducted on social phobia in France to date. It is however a frequent disorder, with often severe alteration of social adaptation and quality of life, and for which effective treatments exist. Thus, it seems really important to further explore how these patients are nowadays identified and treated in psychiatry. It was the objective of the Phœnix study. In this observational multi-center study, 952 psychiatric in- or out-patients, with a primary diagnosis of social phobia according to DSM IV criteria, were included. Numerous diagnostic and psychometric evaluations were carried out, in order to evaluate the comorbidity (Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale), the intensity of social anxiety (Liebowitz Social Anxiety Scale), and various aspects of the functional and emotional impact (Various Impact of Social Anxiety scale, Sheehan Disability Scale, SF-36, Positive and Negative Emotionality scale). The patients were in majority females (57.6 %), with a mean age 37.5 years, and with a mean duration of social anxiety disorder 12.5 years. The mean scores of social anxiety on Liebowitz scale was 40.3±12.6 for the fear factor, and 38.3±13.6 for the avoidance factor. The generalized social anxiety subtype (anxiety in most social situations) was present in 67.8 % of the patients. A major depressive disorder was found in 47.7 % of the sample, and the prevalence of agoraphobia was even higher (49.2 %). As known in clinical practice and in other studies, the prevalence rates of current alcohol dependence and substances abuse were also important in this population (respectively 10.6 % and 12.7 %). Mean scores of the Hospital Anxiety and Depression (HAD) sub-scales were 13.9±3.8 for anxiety and 9.1±4.5 for depression. About 15 % of the patients had a history of suicide attempt, and a suicidal risk was present in nearly 40 % of the sample. The psychosocial impact and the alteration of quality of life (with especially a poor physical health perception) were very significant, in the family, educational or occupational and social domains. Mean scores of the Sheehan Disability Scale were 6.1±2.6 for professional impairment, 5.0±2.7 for familial impairment, and 6.6±2.3 for social life impairment. In addition to the disability due to social phobia intensity, an important part of the burden was due to depressive symptoms. Approximately 60 % of the patients had already a psychiatric treatment at the time of the survey (since 1,7 years in average), but only 17 % had a cognitive behavioral therapy (CBT), and 48 % had an antidepressant treatment. These proportions increased in a significant way after the consultation during which the investigation was carried out : an antidepressant was prescribed to 72 % of the patients, and a CBT is proposed to 48 %. On the whole, this study confirmed the severity and the morbidity of social phobia in a very large sample of French psychiatric patients. The depressive disorders, suicidal risk, and social impairment associated with this condition should incite to more detect and treat it. Seeing the long duration of the disease in our sample, and the lack of specific therapies in many cases, the identification and the treatment of social phobia must be improved, and the role of the psychiatrists in this process seems very important.