Journal of Affective Disorders 130 (2011) 209–212
Contents lists available at ScienceDirect
Journal of Affective Disorders
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d
Research report
Occupational impairment and Social Anxiety Disorder in a sample of primary
care patients
Ethan Moitra a,⁎, Courtney Beard a, Risa B. Weisberg a,b, Martin B. Keller a
a
b
Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, United States
Department of Family Medicine, Alpert Medical School of Brown University, United States
a r t i c l e
i n f o
Article history:
Received 9 June 2010
Received in revised form 7 September 2010
Accepted 18 September 2010
Available online 12 October 2010
Keywords:
Social Anxiety Disorder
Primary care
Occupational functioning
a b s t r a c t
Background: Social Anxiety Disorder (SAD) is the second most prevalent psychiatric condition
in the US. Because of the inherent nature of SAD, it may cause impairments in workplace
functioning, particularly compared to other anxiety disorders that do not necessarily lead to
social impairments. In this study, we compared workplace functioning in primary care patients
with SAD to patients with other anxiety disorders and comorbid Major Depressive Disorder
(MDD).
Methods: Data are obtained from the Primary Care Anxiety Project (PCAP), a naturalistic,
longitudinal study of anxiety disorders in 539 primary care patients. We examined intake
demographic and interviewer-assessed ratings of workplace functioning.
Results: Results revealed that patients with SAD and MDD had significantly decreased
workplace functioning, compared to individuals with other anxiety disorders. Furthermore,
results showed that patients with SAD were greater than two-times more likely to be
unemployed, but expected to work, than all other patients.
Limitations: Workplace functioning was not measured objectively and the sample may not be
representative of the general population.
Conclusions: These findings highlight the particular need to assess for the presence of
undereducation and underperformance at work and/or underemployment in individuals with
SAD, as they are at most risk for these impairments. Additionally, early detection and
intervention in individuals with or at risk for SAD may curb the future impact of social anxiety
on occupational attainment.
© 2010 Elsevier B.V. All rights reserved.
1. Introduction
In the United States, the estimated annual cost of anxiety
disorders is $42.3 billion (Greenberg et al., 1999). This
estimate includes indirect costs, which measure the price of
lost productivity at work and lower wages, among other
factors. These indirect costs are particularly relevant to
understanding the burden of Social Anxiety Disorder (SAD),
⁎ Corresponding author. Brown University, Box G-BH, Providence, RI
02912, United States. Tel.: +1 401 444 1935; fax: +1 401 455 0516.
E-mail address: ethan_moitra@brown.edu (E. Moitra).
0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2010.09.024
the second most common psychiatric disorder in the U.S.
(Kessler et al., 2005), with a lifetime prevalence ranging from
7 to 13% (Furmark, 2002).
SAD usually begins in childhood or adolescence (Rapee,
1995) and can negatively affect school performance, relationships, and mood (Wittchen et al., 1999). Early SAD is a
significant predictor of SAD in adulthood (Pine et al., 1998)
and it has the lowest remission rate among Generalized
Anxiety Disorder (GAD) and Panic Disorder with or without
Agoraphobia (PDA; PD, respectively) (Bruce et al., 2002).
Although SAD does not predict school failure, among the
anxiety disorders, it is the only condition that is predictive of
a person's failure to go on from high school to college
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E. Moitra et al. / Journal of Affective Disorders 130 (2011) 209–212
(Kessler, 2003), suggesting that early development of SAD
leads to undereducation and most likely, underemployment.
This interference is compounded by SAD's chronic, unremitting course (Beard et al., 2010).
Not surprisingly, this early-developed, chronic disorder
leads to long-lasting impairments in normative life roles,
including in the workplace. Adults with SAD report lower
employment rates, lower income, and lower socio-economic status compared to individuals without psychiatric
morbidity (Patel et al., 2002; Stein et al., 2000). For those
who are employed, SAD leads to decreased work productivity, increased absences, and other work impairments
(Kessler et al., 1994; Kessler, 2003; Wittchen and Beloch,
1996; Wittchen et al., 2000). Workplace SAD-related
impairment also manifests in refusal of promotions
because of social fears (Stein et al., 2000) and severity of
SAD is a significant predictor of lower hourly wages
(Katzelnick and Greist, 2001). SAD not only presents a
significant barrier to working full-time, but it can also be
more disruptive to occupational functioning than depression (Tolman et al., 2009).
Antony et al. (1998) found that SAD, Obsessive–
Compulsive Disorder (OCD), and PDA/PD were associated
with similar levels of work impairment. With the exception
of this one study, though, little attention has been paid to
the comparison of workplace functional impairments across
anxiety conditions. These comparisons provide crucial
context to the differential effects of these disorders and
to the understanding of their relative impact on broad
estimates of the effects of anxiety on public health
concerns (e.g., Greenberg et al., 1999). For example,
because of gaps in the literature, it is unclear if occupational impairments associated with SAD differ from those
associated with GAD and if these disorders differentially
contribute to the lost productivity associated with anxiety
disorders. Because of the social impairments associated
with SAD, it is likely that individuals with this disorder
suffer increased occupational impairment compared to
those with other anxiety conditions. Even less attention
has been paid to comparing occupational impairment in
SAD to Major Depressive Disorder (MDD), which itself, is
associated with significant workplace impairments (e.g.,
Stewart et al., 2003). Refined knowledge of these differential effects may clarify epidemiological findings and better
guide what life domains are most salient in assessment and
treatment of anxiety disorders.
The present study sought to refine knowledge of SAD's
effects on occupation by comparing employment rates and
workplace functioning in SAD to other anxiety disorders
and comorbid MDD. In light of previous research, we
hypothesized that patients with SAD would show equivalent occupational impairment to individuals with PD, PDA,
and comorbid MDD. Because of SAD's influence on social
functioning, we predicted that SAD-associated occupational
impairment would be higher than in individuals with GAD
and Posttraumatic Stress Disorder (PTSD). We predicted
that unemployment rates would be higher in SAD,
compared to other conditions. Lastly, we sought to explore
the association between disability status (psychiatric or
medical) and each of these disorders, without specific
directional hypotheses.
2. Methods
2.1. Participants
Participants were part of the Primary Care Anxiety Project
(PCAP), a longitudinal, naturalistic study of 539 primary care
patients with anxiety disorders. Inclusion criteria consisted of
the following: participants were a minimum of 18-years-old,
English was their primary language, they had an index
anxiety disorder, and they presented at the primary care
practice for a medical appointment on the day of recruitment.
Index anxiety disorders were: SAD, PTSD, GAD, PDA, PD,
Agoraphobia without history of Panic Disorder (AWOPD), or
Mixed Anxiety Depressive Disorder (MAD). Due to too few
cases, patients with AWOPD and MAD are not assessed here.
Active psychosis and pregnancy at the time of intake were
exclusion criteria (see Weisberg et al. (2005) for further
details of PCAP methods).
2.2. Procedures
Potential participants completed a screening questionnaire for symptoms of anxiety. Those who screened positive
for the presence of anxiety symptoms were assessed with the
Structured Clinical Interview for the DSM-IV (SCID-IV; First et
al., 1996). Patients who indicated the presence of at least one
index anxiety disorder as defined by the DSM-IV were invited
to join the study. At baseline, these patients completed a
number of measures assessing symptomatology, psychosocial
functioning, and treatments received. Subsequent follow-ups
were obtained at 6-month, 1-year, and annually thereafter.
Only baseline data are analyzed here.
2.3. Measures
2.3.1. Structured Clinical Interview for the DSM-IV (SCID-IV;
First et al., 1996)
Diagnoses were established with the SCID-IV. Several
diagnosticians conducted interviews in order to increase
external validity. All interviews were audiotaped, and interrater reliability on a random sample of 30% of the interviews
was high (intraclass correlation α = 0.96).
2.3.2. Longitudinal Interval Follow-Up Evaluation (LIFE; Keller
et al., 1987)
The LIFE is an interviewer-administered assessment that
collects detailed information on disorder symptoms, psychosocial functioning, and treatment status. Baseline LIFE work
status ratings, for those who were employed, are used here.
These interviewer-assessed ratings represent the degree of
impairment in work activities suffered in the past week. The
quantity and quality of work carried out were assessed on a
five-point Likert scale ranging from 1 (i.e., has worked as
much as someone in his/her social situation would be
expected to work, and worked at a high level) to 5 (i.e., has
missed a great deal of work when someone in his/her social
situation would have been expected to work and/or has been
virtually unable to carry out his work activities when he did
work).
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E. Moitra et al. / Journal of Affective Disorders 130 (2011) 209–212
3. Results
3.1. Descriptive analyses
A total of 539 patients who met DSM-IV criteria for one or
more anxiety disorders were enrolled into the study. One
hundred and eighty-two of these patients met criteria for SAD
(see Table 1 for a summary of demographic variables).
Seventy-one percent met criteria for at least one other
psychiatric disorder at intake and 100% met criteria for
additional comorbid disorders at some point in their lifetime.
Comorbidity patterns in the PCAP sample are described in
detail elsewhere (Rodriguez et al., 2004). Results revealed
SAD age of onset was significantly correlated with education
(r = − 0.015, p = 0.045), with an earlier onset age predicting
lower educational attainment. This trend was also observed
in patients with PDA (r = −0.163, p = 0.046). Educational
attainment and onset age were not significantly correlated in
any other disorder group (ps N 0.05).
3.2. Primary analyses
In a multivariate linear regression model controlling for
educational attainment, results indicated SAD (β = 0.27,
Social Anxiety
Disorder
Other Anxiety
Disorders
(N = 182)
(N = 357)
Characteristic
N (%)
N (%)
Female
Race/ethnicity
Caucasian
African American
Hispanic/Latino
Asian
Native American
Other
Marital status
Never married
Married a
Divorced/separated/
widowed
Education
bHigh school graduate
High school graduate
Some college
College graduate
Income ($ per year)
b5000
5000–9999
20,000–4,999
35,000–49,999
N50,000
Not reported
Employment
Full-time
Unemployed b
Disabled c
Other
Age in years (M, SD)
134 (73.6)
278 (77.9)
147 (80.8)
13 (7.1)
11 (6.0)
3 (1.7)
2 (1.1)
6 (3.3)
300 (84.0)
28 (7.8)
8 (2.2)
4 (1.1)
7 (2.1)
10 (2.8)
51 (28.0)
82 (45.1)
49 (26.9)
96 (26.9)
185 (51.8)
76 (21.3)
20
46
78
38
(11.0)
(25.3)
(42.9)
(20.8)
32
88
151
86
(9.0)
(24.6)
(42.3)
(24.1)
42 (23.2)
66 (36.5)
35 (19.3)
16 (8.8)
16 (8.8)
7 (3.4)
56
130
69
51
37
13
(15.7)
(36.5)
(19.4)
(14.3)
(10.4)
(3.7)
144
19
113
81
39.1
(40.3)
(5.3)
(31.7)
(22.7)
(12.0)
a
b
c
(35.7)
(16.5)
(33.0)
(14.8)
(11.0)
3.3. Secondary analyses
We explored the relationship between diagnosis and
disability (psychiatric or medical). Binary logistic regression
revealed that patients with SAD were less likely to be disabled
(Exp(B) = −0.63; OR = 0.53; 95%CI: [0.30, 0.95]; p = 0.03).
This pattern was also observed in GAD (Exp(B) = −0.79;
OR = 0.45; 95%CI: [0.22, 0.92]; p = 0.03). However, those with
PDA were nearly three-times more likely to be disabled (Exp
(B) = 1.04; OR = 2.82; 95%CI: [1.53, 5.20]; p = 0.001). All
other disorders were not predictive of disability (ps N 0.05).
4. Discussion
Table 1
Socio-demographic characteristics (N = 539).
65
30
60
27
39.1
t = 2.43, p = 0.02) and MDD (β = 0.51, t = 4.59, p b 0.0001)
were unique predictors associated with lower workplace
functioning ratings on the LIFE, whereas all other disorders
were not (ps N 0.05).
Binary logistic regression was used to assess likelihood of
being unemployed depending on diagnosis. Results revealed
that individuals with SAD were greater than two-times more
likely to be unemployed and that individuals with other
anxiety disorders were more likely to be employed. Furthermore, results revealed that MDD was not significantly
predictive of unemployment status (see Table 2 for summary
of odds ratios).
Includes persons living with someone as though married.
Unemployed but expected to work.
Psychiatrically or medically disabled.
Despite knowledge of SAD's chronicity and detrimental
effects on occupational functioning, few researchers have
compared impairment associated with SAD with that related
to other anxiety and mood conditions. By nature, the
workplace may trigger SAD symptoms in particular, and
consequently cause more impairment than in conditions
associated with less social interference (e.g., GAD). This study
addressed this gap in the literature by comparing likelihood
of unemployment and disability (psychiatric or medical)
status, as well as overall workplace functioning in primary
care patients with SAD, GAD, PTSD, PD, PDA, and comorbid
MDD.
Patients with SAD and MDD were significantly more
impaired in the workplace than all other individuals,
regardless of education level. Results also indicated that
patients with SAD were 2.25 times more likely to be
unemployed but expected to work, than patients with any
other psychiatric condition. In fact, results suggested that the
presence of PD, PDA, GAD, and PTSD made a patient more
likely to be gainfully employed compared to patients with
SAD. Exploratory analyses indicated that among the disorders
Table 2
Effect of diagnosis on unemployment status a.
Diagnosis
Exp(B)
OR
95% CI
p
Panic Disorder
Panic Disorder with Agoraphobia
Social Anxiety Disorder
Generalized Anxiety Disorder
Posttraumatic Stress Disorder
Major Depressive Disorder
−1.44
−1.63
0.81
−0.95
−1.33
0.01
0.24
0.20
2.25
0.39
0.27
1.01
[0.08, 0.75]
[0.09, 0.43]
[1.19, 4.26]
[0.17, 0.87]
[0.14, 0.50]
[0.55, 1.86]
0.014
b.0001
0.013
0.023
b.0001
0.971
Note. OR = odds ratio; CI = confidence interval.
a
Unemployed but expected to work.
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E. Moitra et al. / Journal of Affective Disorders 130 (2011) 209–212
examined, individuals with PDA were most likely to be
disabled. This finding suggests that PDA may be the most
debilitating anxiety disorder overall, as these individuals
were not working.
Because of the inherent social nature of most occupations,
it is not surprising that SAD is associated with occupational
impairment and unemployment. However, these results are
the first to the authors' knowledge that demonstrate a
significant difference between SAD and other anxiety disorders in these important domains. These findings highlight
the particular need to assess for the presence of undereducation and underperformance at work in individuals with
SAD.
Strengths of the current study include the large sample
size and the range of comparison disorders. However, the
current study also has limitations, including that it is not an
epidemiological study. Some of the current sample's demographic characteristics (e.g., employment rates), though, are
similar to those found in larger epidemiological studies (e.g.,
Davidson et al., 1993), suggesting that the current findings
might generalize to samples outside of primary care. All
participants had at least one anxiety disorder to qualify for
study entry. Thus, all MDD was comorbid with an anxiety
disorder, whereas not all cases of any of the anxiety disorders
were comorbid. Therefore, the findings indicate that, among
anxiety disorder patients, having comorbid MDD predicts
worse occupational functioning than not having MDD. Finally,
our measure of workplace impairment was an interviewer's
subjective rating based upon patient report. Objective
measures of workplace functioning would bolster the current
findings and should be included in future investigations.
Role of funding source
Funding for this study was provided by an unrestricted grant from Pfizer,
Inc. Pfizer had no further role in the study design; in the collection, analysis
and interpretation of data; in the writing of the report; and in the decision to
submit the paper for publication.
Conflict of interest
Disclosure for Risa B. Weisberg, Ph.D., Consultant Honoraria: Astra
Zeneca, Eli Lilly and Company, Bristol Myers Squibb, and SciMed. Grants
Research: Pfizer. Advisory Boards: None. Major Stockholder: None.
Disclosure for Martin B. Keller, MD., Consultant Honoraria: Abbott,
CENEREX, Cephalon, Cypress Bioscience, Cyberonics, Forest Laboratories,
Medtronic, Organon, Novartis, Pfizer, Shire, Solvay, Wyeth. Grants Research:
Pfizer, Wyeth. Advisory Boards: Abbott Laboratories, CENEREX, Cyberonics,
Cypress Bioscience, Forest Laboratories, Neuronetics, Novartis, Organon,
Pfizer. Major Stockholder: None.
All other authors declare that they have no conflicts of interest.
Acknowledgements
The Primary Care Anxiety Project is supported by an
unrestricted grant from Pfizer Inc. Dr. Beard's time and effort
are supported by a post-doctoral training award from the
National Institute of Mental Health (F32 MH083330). Dr.
Weisberg's time and effort are supported in part by a Career
Development Award from the National Institute of Mental
Health (K23 MH069595).
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