Social Phobia in an Italian region: do Italian studies show lower frequencies than community surveys conducted in other European countries?
© Carta et al; licensee BioMed Central Ltd. 2004
Received: 25 March 2004
Accepted: 15 October 2004
Published: 15 October 2004
The lifetime prevalence of Social Phobia (SP) in European countries other than Italy has been estimated to range from 3.5% to 16.0%. The aim of this study was to assess the frequency of SP in Sardinia (Italy) in order to verify the evidence of a lower frequency of SP in Italy observed in previous studies (from 1.0% to 3.1%).
A randomised cross sample of 1040 subjects, living in Cagliari, in rural areas, and in a mining district in Sardinia were interviewed using a Simplified version of the Composite International Diagnostic Interview (CIDIS). Diagnoses were made according to the 10th International Classification of Diseases (ICD-10).
Lifetime prevalence of SP was 2.2% (males: 1.5%, females: 2.8%) whereas 6-month prevalence resulted in 1.5% (males: 0.9%, females: 2.1%). Mean age at onset was 16.2 ± 9.3 years. A statistically significant association was found with Depressive Episode, Dysthymia and Generalized Anxiety Disorder.
The study is consistent with findings reported in several previous studies of a lower prevalence of SP in Italy. Furthermore, the results confirm the fact that SP, due to its early onset, might constitute an ideal target for early treatment aimed at preventing both the accumulation of social disabilities and impairments caused by anxiety and avoidance behaviour, as well as the onset of more serious, associated complications in later stages of the illness.
Several epidemiological studies have attempted to describe the prevalence, socio-demographic characteristics, comorbidity, and severity of clinical manifestations of Social Phobia (SP). Quality of life and functional status of affected individuals have also been investigated . Lifetime prevalence of SP in European societies other than Italy ranges from 3.5% to 16.0% . As discussed in several excellent review papers, these rate differences were partly attributed to probable genetic or cultural factors . Furthermore, major methodological differences (type of diagnostic criteria used, assessment tools, age of the sample) affecting the estimates have been demonstrated .
This study, part of an extended epidemiological investigation "Health in Sardinia," aimed to assess the prevalence rates of SP in Sardinia (Italy) in order to confirm the evidence of low SP prevalence rates ranging from 1.0% to 3.1% observed in previous research projects in Italy [4–6]. The study also intended to evaluate the treatments and to verify the comorbid psychiatric disorders in the identified people with Social Phobia.
Percentage of subdivision according to age, sex, and marital status of the sample.
Lifetime prevalence of Social Phobia in the general population of Europe and USA.
Faravelli et al., 1989 
Wacker et al., 1992 
Schneier et al., 1992 
Lindal and Stefansson, 1993 
Degonda and Angst, 1993 
Kessler et al., 1994 
Lepine and Lellouch, 1995 
Wittchen et al., 1998 
Carta and Rudas, 1998 
Arillo et al., 1998 [cited in 33]
Bijl et al., 1998 
Lépine and Pélissolo, 1999 
Faravelli et al., 2000 
Carta et al., 2002 
Lifetime prevalence N (%) of Social Phobia according to age and sex.
Six month prevalence N (%) of Social Phobia according to age and sex.
During the week prior to the study, 8 (50.0%) out of the 16 subjects who had been diagnosed with SP over the past six months had been taking low doses of anxiolytics (less than the equivalent of 2 mg of Lorazepam). 3 (18.7%) were on antidepressants, one of whom (6.2%) at non-therapeutic doses, and 1 subject (6.2%) was undergoing cognitive behavioural psychotherapy. The remaining 6 subjects (37.5%) were not on any treatment.
Six out of the 10 treated subjects (60%) were being supervised by their general practitioners (GP), 1 (10%) by a neurologist and 2 (20%) by psychiatrists. All subjects presented some degree of comorbidity with Depressive Episodes (DE), Panic Attack Disorder (PAD), and agoraphobia (AP). Only 1 subject (10%) was undergoing cognitive behavioural therapy with a psychologist/psychotherapist.
Lifetime comorbidity of Social Phobia.
Depressive Episode (DE)
Generalized Anxiety Disorder (GAD)
Panic Attack Disorder (PAD)
Several epidemiological studies carried out in Europe (Switzerland [16, 21], France [19, 22], Germany ) and in the USA [15, 17], recently reviewed by Furmark , suggest that SP is one of the more frequently observed anxiety disorders in the general population in Western countries. However, frequency rates reported in the various studies differ from country to country and according to time and evaluation methods used. Indeed, the two American studies [15, 17] carried out at an interval of approximately 15 years, illustrate distinctly contrasting results, and it is hard to establish what factors really determine variance in findings.
The present study is consistent with the tendency towards rather low lifetime prevalence rates of SP observed in other Italian research projects. If we take into account only those European researches that adopted ICD-10 diagnosis, our results seem to indicate a lower frequency than a study carried out in Formentera, Spain (lifetime prevalence of 2.8% against 8.9% in females [cited in ]) and Basel, Switzerland (lifetime prevalence in the total sample 2.2 against 9.6% ). However, lower frequencies emerged also in Italian surveys conducted using different methods [5, 7]. The Italian studies were carried out over a considerable period of time and in two distinct areas: the Florence area [4, 5] and Sardinia [, the present study]. It is therefore quite likely that the lower frequencies observed may be the result of an effectively reduced vulnerability of Italians to SP. The results of this study can indeed be assumed as being influenced by several cultural variables – the genetic diversity of the two populations examined, as well as the considerable genetic variance of the Sardinian population respect to other European populations [24, 25].
Findings for six-month prevalence show lower frequencies than those evidenced in the recent studies: 1.5% against 4.0% in Iceland  and against 4.0% in Munich . Our rates are lower than E.C.A. findings: 2.7% in Duke  and 2.2% in Baltimore, New Haven, and Saint Louis . The 6-month prevalence rates obtained in Sardinia are similar only to data reported for Edmonton (1.2%) from a survey carried out more than 15 years ago  and published in 1994 . However, the prevalence data emerging from this study further justify the considerable interest shown in this disorder from both a medical and a social point of view. This research confirms the fact that onset of the illness occurs primarily during childhood and adolescence , thus underlining the suitability of the condition as a candidate for early treatment aimed at preventing both the slow accumulation of social disabilities and impairment caused by anxiety and by avoidance behaviour, as well as the onset of more serious complications (e.g., DE or GAD), which may be manifested many years after onset of SP. Indeed, subjects affected by social phobia presented a high risk of comorbidity with both the latter disorders and DD  .
It should be underlined that 60% of subjects undergoing treatment (not all affected subjects) chose their general practitioner (GP). This view is corroborated by the fact that those patients treated by a psychiatrist invariably presented comorbidity with DE, PAD, and AP, thereby representing the more severely affected from a psychopathological point of view. Overall however, the low rate of patients with SP treated with first line-treatments is alarmingly low.
In the future, serious attempts should be made to improve the GPs' abilities to recognise SP in order to prevent the use of inappropriate treatments, such as insufficient doses of benzodiazepines, which may be linked to the physician's incorrect diagnosing of the disorder. Due to the fact that subjects affected by SP most frequently refer to their GP, the importance of preventing SP as opposed to other types of disorders, as well as the markedly incapacitating nature of SP reinforce this necessity for a better training of GPs.
It is however mandatory to briefly acknowledge some potential limitations of this study. First, the number of cases and the sample size is too small to allow firm conclusions to be drawn concerning the true rate and the degree to which they might actually differ from previous studies with higher estimates. Secondly, differences in the assessment strategy might have resulted in a diminished comparability.
The study is consistent with findings reported in several previous studies of a lower prevalence of Social Phobia in Italy and confirms the fact that onset of the illness occurs primarily during childhood and adolescence. Furthermore, the results confirm the fact that SP, due to its early onset, might constitute an ideal target for early treatment aimed at preventing both the accumulation of social disabilities and impairments caused by anxiety and avoidance behaviour, as well as the onset of more serious, associated complications in later stages of the illness, or many years after onset of SP.
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