Answers

Short answers

1. The patient seems to be moderately depressed and is a habitual drinker, but these are the consequences of a social phobia.

2. You should clarify the nature of his anxiety—how specific is his anxiety to particular situations, how avoidant has he become, what is the nature of his associated cognitions and worries? You should also ask about his mood, his risk of self harm or suicide, and his past and current substance use.

3. Advise the patient that evidence exists that cognitive behavioural therapy and SSRIs are effective treatments for social anxiety and depression.

Long answers
1. Social phobia
The patient has social phobia and also seems to have symptoms of depression. He may have generalised anxiety disorder. The box shows the ICD-10 (international classification of diseases, 10th revision) descriptions of these disorders.¹

It is common for people with anxiety disorders to self medicate with alcohol around known triggers; it is equally common for people with chronic untreated anxiety disorders to be depressed and tired. In community surveys, 49-78% of people with a social phobia have a concurrent mood disorder or a second anxiety disorder^{2 3 4}—16.7-20% of them misuse alcohol or are dependent on it.^{2 4}

The amount of alcohol that he is consuming could impair his health; however, his drinking seems to be situation specific—it has not had any serious consequences (such as criminal charges, health difficulties, or marital difficulties)—so he is unlikely to be a harmful drinker. He might possibly have alcohol dependency—you should ask him about alcohol withdrawal syndrome.

2. Questions to ask when you see the patient again
This vignette is a fairly common presentation of social phobia, which tends to occur in a context where mood symptoms, other anxiety symptoms, and (less commonly) symptoms of substance misuse are present. The key to this case is to assess the nature of his anxiety.

Did his chronic drinking and his lowered mood develop after his anxious mood? How situation specific is his anxiety? How avoidant has he become of social situations? Ask what the alcohol does in social situations (or what happens if he does not drink alcohol). Ask about other anxiety symptoms (generalised worry, panic, other phobias, obsessions). You need to explore the nature of his depression. Does he have problems with concentration and memory or thoughts of worthlessness, hopelessness, and self harm? Confirm that he is not overly guilty or anxious because of delusional thoughts, particularly negative ones. Confirm he does not have any suicidal ideation.

The Canadian guidelines on anxiety disorders suggest that all anxious, depressed patients or patients misusing alcohol should be asked these three screening questions⁵:

1. Are you uncomfortable or embarrassed at being the centre of attention?

2. Do you find it hard to interact with people?

3. Do you blush and tremble when asked to do things in public, like speak, eat, or sign a cheque?

You also need to understand the nature of his drinking. Some guidelines suggest that men can drink up to 21 standard drinks a week,⁶ and up to eight drinks in a session,⁷ but some people have difficulty keeping below these limits.⁸ The CAGE questionnaire can help ascertain whether or not he is dependent on alcohol.⁹ Questions include, "have you felt the need to cut down alcohol?" "have you been abstinent for a period?" "how guilty do you feel about your alcohol use?," and "do you need a drink in the morning to get going?" Check also for other consequences of his drinking including marital discord, financial difficulties, legal problems (especially driving), and problems at work to see how invasive his drinking has become.

3. Advice about adherence to drugs
Two recent meta-analyses have looked at pharmacological treatment of social phobia. The first review used Cochrane methodology (search date 2003) and identified 37 randomised controlled trials—17 trials of SSRIs, three of monoamine oxidase inhibitors (phenelzine), nine of reversible monoamine oxidase inhibitors (six of moclobemide, three of brofaromine), and nine other studies, which included three trials of benzodiazepines. The pooled data indicated that drugs were more efficacious at reducing symptoms and minimising disability than placebo, and subanalysis indicated that this was true for SSRIs and reversible and non-reversible monoamine oxidase inhibitors. The SSRIs had a lower dropout rate than the other groups,⁶ and they do not have problems relating to dietary restrictions (as do monoamine oxidase inhibitors) or dependence (as do benzodiazepines).¹⁰ The second review (search date 2004) identified 15 controlled trials—paroxetine 20-60 mg/day, fluvoxamine 100-300 mg/day, escitalopram 10-20 mg/day, fluoxetine 10-60 mg/day, and sertraline 50-200 mg/day were all efficacious when compared with placebo.¹¹

Large effects sizes have been reported for the use of cognitive behavioural therapy in anxiety—meta-analyses suggest that it is highly effective in adults with a range of disorders, including generalised anxiety disorder and social phobias.¹² Evidence exists for its long term effectiveness in anxiety disorders.¹³ The benefit of combining cognitive behavioural therapy with drug treatment is unclear because few well controlled trials have looked at single versus combined treatment for social phobia and generalised anxiety disorder. Cognitive therapy is also an efficacious treatment for social phobia,¹⁴ and it seems to have ongoing benefits when combined with drugs or used alone.¹⁵ If the patient does wish to continue with therapy alone for his social phobia, management of somatic symptoms of anxiety (through relaxation, imagery, mindfulness, and so on) and a graded exposure to anxiogenic situations (without alcohol) will need to be included.¹⁶ This will extend the time needed for treatment.

Cite this as: BMJ 2008;337:a1241