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Social Anxiety Disorder

Social Anxiety Disorder. Danielle Herring. DSM-5. DSM-5 Changes. Social Anxiety Disorder (SAD). Found under Anxiety Disorders Other disorders also listed: Separation Anxiety Disorder Selective Mutism Specific Phobia Panic Disorder Panic Attack Specifier Agoraphobia

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Social Anxiety Disorder

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  1. Social Anxiety Disorder Danielle Herring

  2. DSM-5

  3. DSM-5 Changes

  4. Social Anxiety Disorder (SAD) • Found under Anxiety Disorders • Other disorders also listed: • Separation Anxiety Disorder • Selective Mutism • Specific Phobia • Panic Disorder • Panic Attack Specifier • Agoraphobia • Generalized Anxiety Disorder • Substance/Medication-Induced Anxiety Disorder • Anxiety Disorder Due to Another Medical Condition • Other Specified Anxiety Disorder • Unspecified Anxiety Disorder

  5. Social Anxiety Disorder (SAD) • Essential feature: • Social anxiety disorder is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others.

  6. Diagnostic Criteria • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).Note: In children, the anxiety must occur in peer settings and not just during interactions with adults. • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). • The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. • The social situations are avoided or endured with intense fear or anxiety. • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

  7. Diagnostic Criteria • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. • If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. Specifyif: Performance only: If the fear is restricted to speaking or performing in public.

  8. Diagnostic Specifier • Performance Only: • Performance fears that typically impair one’s professional life • Can manifest in work, school, or academic settings • Those with performance only SAD do not fear or avoid nonperformance social situations.

  9. Associated Features • Inadequately assertive or excessively submissive behavior • Rigid body posture • Inadequate eye contact • Overly soft voice tone • Blushing – hallmark physical response to SAD

  10. Prevalence of SAD • 12-month prevalence estimate for the United States is approximately 7% • 12-month prevalence rates in children and adolescents are comparable to those in adults • Lower 12-month prevalence estimates are seen in much of the world using the same diagnostic instrument, clustering around 0.5%–2.0% • Prevalence rates decrease with age • 12-month prevalence for older adults ranges from 2% to 5% • Generally, higher rates found in females than males in the general population - odds ratios ranging from 1.5 to 2.2:1 • Gender difference in prevalence is more pronounced in adolescents and young adults • Median prevalence in Europe is 2.3% • Prevalence in the United States is higher in American Indians and lower in persons of Asian, Latino, African American, and Afro-Caribbean descent compared with non-Hispanic whites

  11. Development & Course of SAD • Median age at onset of social anxiety disorder in the United States is 13 years. • 75% of individuals have an age at onset between 8 and 15 years • Onset can also occur in early childhood. • First onset in adulthood is relatively rare. • Onset of social anxiety disorder may follow a stressful or humiliating experience or may develop slowly . • In the community ~30% of individuals experience remission of symptoms within 1 year, and ~50% experience remission within a few years. • Without a specific treatment, for ~60% of individuals course will take several years or longer.

  12. Risk Factors of SAD • Environmental: • Childhood maltreatment & adversity (not causal) • Temperamental: • Underlying traits that predispose for SAD include behavioral inhibition & fear of negative evaluation • Genetic/Physiological: • Traits predisposing individuals, such as behavioral inhibition, are strongly genetically influenced • Genetic influence is subject to gene-environment interaction • SAD is heritable (performance-only anxiety less so) • First-degree relatives have a two to six times greater chance of having SAD

  13. Comorbidity • Often comorbid with bipolar disorder, body dysmorphic disorder, other anxiety disorders, major depressive disorder, and substance use disorders • Onset of SAD generally precedes the other disorders, except for specific phobia and separation anxiety disorder • SAD (but not SAD, performance only) is often comorbid with avoidant personality disorder • In children, comorbidities with high-functioning autism and selective mutism are common • Females - higher comorbidity with depressive, bipolar, and anxiety disorders • Males - more likely to have ODD or CD and use alcohol or illicit drugs to relieve symptoms of SAD

  14. DSM-5 Model of SAD • Temperamental Factors: • Behavioral inhibition • Fear of negative evaluation Genetic/ Physiological Factors • Core Features: • Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others • Environmental Factors: • Childhood maltreatment & adversity • Performance Only Specifier: • If the fear is restricted to speaking or performing in public. • Associated Features: • Inadequately assertive or excessively submissive • Rigid body posture • Inadequate eye contact • Overly soft voice tone • Blushing

  15. Literature Review

  16. Onset & Prevalence • Generally in late childhood/early adolescence. Not usually diagnosed before age 10 (Weis, 2008). • Mean age of onset 15.1 years (Fink et al., 2009). • Average age of onset is considered mid-adolescence (Schneier et al., 1992). • Lifetime prevalence of 12% and 12 month prevalence of 7.1% (Kessler et al., 2005). • Lifetime prevalence between 5% and 15% (Heimberg et al., 2000).

  17. Typical Course • Most children do not have SAD long term (Weis, 2008). • Cited: • Pine, Cohen, Gurley, Brook & Ma (1998), most adolescents did not continue to meet diagnostic criteria in adulthood. • An epidemiologically selected sample of 776, 9–18 year olds, were evaluated with structural interviews in 1983, 1985, and 1992. • Last, Perrin, Hersen, & Kazdin (1996) • In a study of 84 children, about half did not show the disorder 3 years after the initial diagnosis.

  18. Commonly Feared Situations • Most common feared situations: formal presentations & unstructured social interactions. • Intense anxiety reported for: • Reading aloud in class • Giving a class presentation • Performing for others on stage • Performing at an athletic event • (Weis, 2008). • Giving a speech, participating in a meeting, talking to people they do not know (Fink et al., 2009).

  19. Commonly Feared Situations

  20. Associated Risk Outcomes • Academic underachievement • Underperformance at work • Inability to work • Higher rates of alcohol and drug abuse • Higher unemployment rates in patients with SAD • Fink et al., 2009

  21. Comorbidity • Depression, social isolation, substance use problems (Weis, 2008). • Bipolar disorder (22% BD patients had experienced SAD) • Eating disorders • Other anxiety disorders • Selective mutism • ODD • CD • Rates on following slide…

  22. The National Comorbidity Survey Replication–Adolescent Supplement is a nationally representative face-to-face survey of 10,123 adolescents 13 to 18 years of age in the continental United States.

  23. Genetic Factors • Family studies – tendency to experience anxiety runs in families . • Twin studies – 50% of variance in symptoms attributable to genetics (Weis, 2008). • First-degree relatives of adults with SAD are 3x as likely to be affected with SAD (Ollendick & Hirshfeld-Becker, 2002). • Family studies have consistently found significantly higher rates of SAD in the relatives of socially phobic probands (Fyer, Mannuzza, Chapman, martin, & Klein, 1995; Hughes, Furr, Sood, Barmish, & Kendall, 2009; Reich & Yates, 1988).

  24. Genetic Factors cont. • Twin studies have consistently found evidence for the heritability of general traits: • Behavioral inhibition (33%) • Shyness (22%) • Fear of negative evaluation • (Daniels & Plomin, 1985; Eley et al., 2003; Stein, Goldin, Sareen, Zorrilla, & Brown, 2002; Warren, Schmitz, & Emde, 1999) • Beatty, Heisel, Hall, Levine, & La France conducted a meta-analysis of twin studies. Heritability estimate of .65 for SAD (2002). • Controversy surrounding twin studies: • Kendler, Neale, Kessler, Heath, and Eaves (1992) found a higher concordance rate for SAD among MZ (24%) than DZ (15%) female twins • Skre, Onstad, Torgersen, Lygren, & Kringlen found similar concordance rates for SAD among MZ and DZ twins, suggesting that there is not a specific genetic contribution (1993).

  25. Environmental Factors • Parent-child interactions: • Parents of children with social phobia: • Generally more controlling & overprotective • High levels of critical behavior toward children • Avoid emotional-charged discussions • Likely to have social anxiety – anxiety responses can be taught, modeled, or reinforced. • Dadds, Barrett, Rapee, & Ryan (1996) - Ambiguous situations interpreted as hostile/dangerous by children. Parents supposed children’s decisions to overreact and withdraw from social situations. • Interactions bidirectional – children’s behavior can also cause parents to be controlling, protective, or critical (Weis, 2008)

  26. Environmental Factors cont. • Lieb et al. (2000) – parental rejection and overprotection more frequent when parents had psychopathology • Parents of individuals with social anxiety are inclined to be more socially isolated (Caster et al., 1999). • Less likely to facilitate play dates, supervise peer interactions, or monitor activities (Masia & Morris, 1998).

  27. Temperamental Factors • Behavioral inhibition (BI) marks an increased risk for anxiety disorders in general and SAD specifically (Higa-McMillan & Ebesutani, 2011). • Manifests differently at different stages: • Inhibited toddlers: React to new things/situations with fear, clinging, and avoidance • Inhibited elementary school children: Quiet isolation with unfamiliar peer groups, shyness with unfamiliar adults • Kagan et al. (1994) – followed 2 independent cohorts of inhibited toddlers -> BI moderately preserved through early adolescence. • Biederman et al. (2001) found that SAD more common among children with BI than without BI.

  28. Temperamental Factors • Hayward et al. (1998) found that adolescents with childhood BI were at 4 to 5 times greater risk of developing SAD than those who did not exhibit BI (sample of 2000 ninth graders with retrospective self-report measures). • Hirshfeld-Becker et al. (2007): 5-year follow-up study and found that BI specifically predicted the onset of SAD and was not associated with any other anxiety disorders. • Biederman et al. (1993): • 216 inhibited and non-inhibited children from a sample of parents with panic disorder and/or MDD and non-anxious and non-depressed controls. • Inhibited subjects had higher rates of either SAD and avoidant disorder (DSM-III-TR) • Does not specify number split

  29. Neurobiological Factors • Dopaminergic dysregulation • Tiihonen et al., (1997), reported that striatal dopamine reuptake site densities were lower among SAD patients than a comparison group matched on age and gender. (11 patients with SAD and 11 healthy controls). • SAD patients with low dopaminergic activity also found by Schneier et al., (2000). • Atypical serotonergic functioning • Respond well to drugs inhibiting serotonin reuptake (SSRIs) (Bouwer & Stein, 1998; Katzelnick et al.,1995) • Tanceret al. (1994–1995): Greater cortisol responses to fenfluramine than a comparison group without anxiety—reflecting differential levels of stimulation of central serotonin 5-HT2C receptors. • Lanzenbergeret al., (20070: PET study also identified reduced binding of a specific serotonin receptor (5-HT1A) related to SAD.

  30. Neurobiological Factors cont. • 2004 – Gelernter et al. conducted first genome wide linkage study in SAD patients. • Suggested linkage of chromosome 16 markers near norepinephrine transporter protein • Smollen et al – strong association of corticotropin releasing hormone (CRH) gene and BI (2005). • Etkin & Wager, 2007 – fMRI studies that show hyperactive areas during emotional processing of SAD patients: • Parahippocampal and fusiform gyrus • Interior frontal gyrus • Amygdala* • Insula* • * - most consistently found to be hyperactive

  31. Neurobiological Factors cont. • 2007 – Lanzenberger et al., PET study of serotonergic contribution to pathophysiology of SAD. • Compared5-HT1A receptor in male SAD (12) and control patients (18) • SAD patients appear to have lower receptor binding in mesiofrontal areas, the amygdala and insula, which are assumed to be part of the neural circuitry of SAD.

  32. Conditioning Factors • Direct exposure to socially traumatic events is believed to mark the onset or dramatic increase of symptoms (Higa-McMillan & Ebesutani, 2011). • Many individuals with SAD can recall a past traumatic event associated with the onset of their disorder (Beidel& Turner, 2007). • Östand Hugdahl- 58% of their SAD sample reported that their SAD-related fears were the result of direct, traumatic social experiences (1981).

  33. Conditioning Factors • Stemberger, Turner, Beidel, & Calhoun - 56% of individuals with specific SAD and 40% of individuals with generalized SAD recalled a traumatic event that precipitated the onset and/or increase in their symptoms (1995). • 92% of adult sample diagnosed with SAD (n=26) reported a history of severe teasing in childhood (McCabe, Antony, Summerfeldt, Liss, & Swinson, 2003).

  34. Developmental Model of the etiology of SAD in adolescents Higa-McMillan & Ebesutani, 2011.

  35. My Model of SAD • Comorbidity: • Depression • Social isolation • Substance use problems • Bipolar Disorder • Other anxiety disorders Cultural Factors Conditioning Factors/ Parenting Style • Core Feature: • Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others Environmental Factors Temperamental/ Genetic Factors Neurobiological Factors • Performance Only • Secondary Features: • Inadequately assertive or excessively submissive • Rigid body posture • Inadequate eye contact and Overly soft voice tone • Blushing • Academic underachievement • Underperformance at work • Inability to work • Alcohol and/or drug use • Increased possibility of unemployment

  36. References Beatty, M., Heisel, A., Hall, A., Levine, T., & La France, B. (2002). What can we learn from the study of twins about genetic and environmental influences on interpersonal affiliation, aggressiveness, and social anxiety?: A meta-analytic study. Communication Monographs, 69, 1–18. doi:10.1080/03637750216534 Beidel, D. C., & Turner, S. M. (2007). Shy children, phobic adults: The nature and treatment of social anxiety disorder (2nd ed.). Washington, DC: American Psychological Association. doi:10.1037/11533-000 Biederman, J., Hirshfeld-Becker, D. R., Rosenbaum, J. F., Hérot, C., Friedman, D., Snidman, N., . . . Faraone, S. V. (2001). Further evidence of association between behavioral inhibition and social anxiety in children. The American Journal of Psychiatry, 158, 1673–1679. doi:10.1176/appi.ajp.158.10.1673 Bouwer, C., & Stein, D. J. (1998). Use of the selective serotonin reuptake inhibitor citalopram in the treatment of generalized social phobia. Journal of Affective Disorders, 49, 79–82. doi:10.1016/S0165-0327(97)00182-1 Burstein, M., He, J., Kattan, G., Albano, A., Avenevoli, S., & Merikangas, K. R. (2011). Social phobia and subtypes in the National Comorbidity Survey–Adolescent Supplement: Prevalence, correlates, and comorbidity. Journal Of The American Academy Of Child & Adolescent Psychiatry, 50(9), 870-880. doi:10.1016/j.jaac.2011.06.005

  37. References Daniels, D., & Plomin, R. (1985). Origins of individual differences in infant shyness. Developmental Psychology, 21, 118–121. doi:10.1037/0012-1649.21.1.118 Eley, T. C., Bolton, D., O’Connor, T. G., Perrin, S., Smith, P., & Plomin, R. (2003). A twin study of anxiety-related behaviours in pre-school children. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 44, 945–960. doi:10.1111/1469-7610.00179 Fink, M., Akimova, E., Spindelegger, C., Hahn, A., Lanzenberger, R., & Kasper, S. (2009). Social anxiety disorder: Epidemiology, biology and treatment. PsychiatriaDanubina, 21(4), 533-542. Fyer, A. J., Mannuzza, S., Chapman, T. F., Martin, L. Y., & Klein, D. F. (1995). Specificity in familial aggregation of phobic disorders. Archives of General Psychiatry, 52, 564– 573. Hayward, C., Killen, J., Kraemer, H., & Taylor, B. (1998). Linking self-reported childhood behavioral inhibition to adolescent social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 1308–1316. doi:10.1097/00004583- 199812000-00015 Higa-McMillan, C. K., & Ebesutani, C. (2011). The etiology of social anxiety disorder in adolescents and young adults. In C. A. Alfano, D. C. Beidel (Eds.) , Social anxiety in adolescents and young adults: Translating developmental science into practice (pp. 29-51). Washington, DC US: American Psychological Association. doi:10.1037/12315-002

  38. References Hirshfeld-Becker, D. R., Biederman, J., Henin, A., Faraone, S., Davis, S., Harrington, K., & Rosenbaum, J. (2007). Behavioral inhibition in preschool children at risk is a specific predictor of middle childhood social anxiety: A five-year follow-up. Journal of Developmental and Behavioral Pediatrics, 28, 225–233. doi:10.1097/01.DBP.0000268559.34463.d0 Hughes, A. A., Furr, J. M., Sood, E. D., Barmish, A. J., & Kendall, P. C. (2009). Anxiety, mood, and substance use disorders in parents of children with anxiety disorders. Child Psychiatry and Human Development, 40, 405–419. doi:10.1007/s10578-009-0133-1 Katzelnick, D. J., Kobak, K. A., Greist, J. H., Jefferson, J. W., Mantle, J. M., & Serlin, R. C. (1995). Sertraline for social phobia: A double blind, placebo-controlled crossover study. The American Journal of Psychiatry, 152, 1368–1371. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. Lanzenberger, R. R., Mitterhauser, M., Spindelegger, C., Wadsak, W., Klein, N., Mien, L., . . . Tauscher, J. (2007). Reduced serotonin-1A receptor binding in social anxiety disorder. Biological Psychiatry, 61, 1081–1089. doi:10.1016/j.biopsych.2006.05.022 Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1996). A prospective study of childhood anxiety disorders. Journal Of The American Academy Of Child & Adolescent Psychiatry,35(11), 1502-1510.

  39. References Öst, L. G., & Hugdahl, K. (1981). Acquisition of phobias and anxiety response patterns in clinical patients. Behaviour Research and Therapy, 19, 439–447. doi:10.1016/0005- 7967(81)90134-0 Reich, J., & Yates, W. (1988). Family history of psychiatric disorders in social phobia. Comprehensive Psychiatry, 29, 72–75. doi:10.1016/0010-440X(88)90039-9 Stein, M. B., Chartier, M. J., Hazen, A. L., Kozak, M. V., Tancer, M. E., Lander, S., . . . Walker, J. R. (1998). A direct-interview family study of generalized social phobia. The American Journal of Psychiatry, 155, 90–97 Stein, M. B., Goldin, P. R., Sareen, J., Zorrilla, L. T., & Brown, G. G. (2002). Increased amygdala activation to angry and contemptuous faces in generalized social phobia. Archives of General Psychiatry, 59, 1027–1034. doi:10.1001/arch psyc.59.11.1027 Stemberger, R. T., Turner, S. M., Beidel, D. C., & Calhoun, K. S. (1995). Social phobia: An analysis of possible developmental factors. Journal of Abnormal Psychology, 104, 526–531. doi:10.1037/0021-843X.104.3.526 Tancer, M. E., Mailman, R. B., Stein, M. B., Mason, G. A., Carson, S. W., & Golden, R. N. (1994– 1995). Neuroendocrine responsivity to monoaminergic system probes in generalized social phobia. Anxiety, 1, 216–223.

  40. References Tiihonen, J., Kuikka, J., Bergström, K., Lepola, U., Koponen, H., & Leinonen, E. (1997). Dopamine reuptake site densities in patients with social phobia. The American Journal of Psychiatry, 154, 239–242. Warren, S. L., Schmitz, S., & Emde, R. N. (1999). Behavioral genetic analyses of self-reported anxiety at 7 years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1403–1408. doi:10.1097/00004583-199911000-00015 Weis, Robert. (2008). Abnormal Child and Adolescent Psychology. California: Sage Publications.

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