Social Anxiety Disorder

Danielle Herring

DSM-5

DSM-5 ChangesDSM-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 DisorderSelective MutismSpecific PhobiaPanic DisorderPanic Attack SpecifierAgoraphobiaGeneralized Anxiety DisorderSubstance/Medication-Induced Anxiety DisorderAnxiety Disorder Due to Another Medical

ConditionOther Specified Anxiety DisorderUnspecified 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 CriteriaA. 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.

B. 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).

C. 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.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

Diagnostic CriteriaF. 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 SpecifierPerformance 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 FeaturesInadequately 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 SADEnvironmental:

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

ComorbidityOften 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

Genetic/Physiological Factors

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

Environmental Factors:• Childhood

maltreatment & adversity

Temperamental Factors:• Behavioral inhibition• Fear of negative

evaluation

Performance Only Specifier:• If the fear

is restricted to speaking or performing in public.

Literature Review

Onset & PrevalenceGenerally 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 CourseMost 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 SituationsMost 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 OutcomesAcademic underachievement Underperformance at work Inability to workHigher rates of alcohol and drug abuseHigher unemployment rates in patients with SADFink et al., 2009

ComorbidityDepression, social isolation, substance use

problems (Weis, 2008).Bipolar disorder (22% BD patients had

experienced SAD)Eating disordersOther anxiety disordersSelective mutismODDCD

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 FactorsFamily 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 & overprotectiveHigh 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 FactorsBehavioral 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.

Temperamental FactorsHayward 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 FactorsDopaminergic 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 5-HT2C 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 proteinSmollen 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 FactorsDirect 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).

Öst and Hugdahl - 58% of their SAD sample reported that their SAD-related fears were the result of direct, traumatic social experiences (1981).

Conditioning FactorsStemberger, 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

Temperamental/ Genetic Factors

Neurobiological Factors

Environmental Factors

Core Feature: Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others

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

Comorbidity:• Depression• Social

isolation• Substance

use problems

• Bipolar Disorder

• Other anxiety disorders

Conditioning Factors/ Parenting Style

Cultural Factors

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