Social Anxiety Disorder Danielle Herring DSM-5 DSM-5 Changes DSM-IV-TR DSM-5 Previously designated Social Phobia (Social Anxiety Disorder) Now designated as Social Anxiety Disorder (Social Phobia) Individuals over 18 must recognize their anxiety is excessive or unreasonable Anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account (minimize overdiagnosis of transient fears) 6-month duration for individuals over 18 6-month duration for all ages Generalized specifier (if fears include most social situations) Generalized specifier deleted. Replaced with a “performance only” specifier. 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 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. Diagnostic Criteria A. Marked fear or anxiety about one or more social situations in B. C. D. E. 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. Diagnostic Criteria F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. 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. I. 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. J. 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. Specify if: Performance only: If the fear is restricted to speaking or performing in public. 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. Associated Features Inadequately assertive or excessively submissive behavior Rigid body posture Inadequate eye contact Overly soft voice tone Blushing – hallmark physical response to SAD 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 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. 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 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 DSM-5 Model of SAD Temperamental Factors: • Behavioral inhibition • Fear of negative evaluation Genetic/ Physiological Factors Environmental Factors: • Childhood maltreatment & adversity Core Features: Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others Associated Features: • Inadequately assertive or excessively submissive • Rigid body posture • Inadequate eye contact • Overly soft voice tone • Blushing Performance Only Specifier: • If the fear is restricted to speaking or performing in public. Literature Review 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). 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. 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). Commonly Feared Situations 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 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… 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. 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). 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). 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) 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). Temperamental Factors Behavioral inhibition (BI) marks an increased risk for anxiety disorders in general and SAD specifically (HigaMcMillan & 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. 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 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) Tancer et al. (1994–1995): Greater cortisol responses to fenfluramine than a comparison group without anxiety— reflecting differential levels of stimulation of central serotonin 5HT2C receptors. Lanzenberger et al., (20070: PET study also identified reduced binding of a specific serotonin receptor (5-HT1A) related to SAD. 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 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. Conditioning Factors Direct exposure to socially traumatic events is believed to mark the onset or dramatic increase of symptoms (HigaMcMillan & Ebesutani, 2011). Many individuals with SAD can recall a past traumatic event associated with the onset of their disorder (Beidel & Turner, 2007). Öst and Hugdahl - 58% of their SAD sample reported that their SAD-related fears were the result of direct, traumatic social experiences (1981). 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). Developmental Model of the etiology of SAD in adolescents Higa-McMillan & Ebesutani, 2011. My Model of SAD Conditioning Factors/ Parenting Style Environmental Factors Temperamental/ Genetic Factors Neurobiological Factors Performance Only Cultural Factors Core Feature: Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others Comorbidity: • Depression • Social isolation • Substance use problems • Bipolar Disorder • Other anxiety disorders 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 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 References Daniels, D., & Plomin, R. (1985). Origins of individual differences in infant shyness. Developmental Psychology, 21, 118–121. doi:10.1037/0012-16188.8.131.52 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. Psychiatria Danubina, 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:10.1097/00004583199812000-00015 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 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. 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:10.1016/00057967(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. 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.