Social Anxiety Disorder BY Krista Barr Jackie Kovacs

Social Anxiety Disorder BY: Krista Barr, Jackie Kovacs, Ashley Lupo, Karley Mannino, and Natalie Shaver

Statement of the Problem Social phobia, or social anxiety disorder is “an anxiety disorder characterized by overwhelming anxiety and excessive selfconsciousness in everyday social situations. SAD ranks third most common psychiatric disorder in the United States. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work, school, or other activities

How is the selected psychopathology a problem in our society? Approximately 5. 3 million Americans are affected by social phobia.

What is the impact of this disorder on individuals, families, communities? While anxiety disorders, by their very nature, isolate those who suffer from them, they are also isolating for members of the victim's family. The resulting family dysfunction caused by anxiety disorders often results in the problem becoming further complicated by the psychological and physical reactions of other family members. It is just as important for the people who are directly affected - whether as sufferers of anxiety disorders or as family members - to attempt to communicate the facts within their individual circles of friends and acquaintances to create understanding.

Discuss financial, educational, health, legal and other relevant ramifications of this disorder (i. e. what is the cost to society of this disorder). Individuals also jeopardize their health regularly because they avoid going to health professionals which can be detrimental for receiving treatment in a timely fashion and can be dangerous, as well as cause significant financial burden. Social phobia can prevent people from going to class to get a degree to better their lives, as well as people who fear public speaking may decline a promotion that they so desperately need because the job entails that they must do presentations. In these situations and many others, the consequences can have serious ramifications to health issues which can be costly as well.

What factors may contribute to the development of this disorder (e. g. poverty, discrimination, oppression, nutrition/health, familial factors/influences, genetic influenced (if so, give concordance rates), environmental [pollution etc. ], abuse, neglect, and trauma). Factors that contribute to SAD are: Familial factors- parenting attributes such as overcontrol -result in less child autonomy, and to a lesser extent lack of warmth or rejection resulting in insecure attachment. Traumatic events such as bullying, familial violence, sexual and physical abuse are linked to the development of SAD as these events induce stress and create anxiety. SES disadvantage > risk of anxiety disorders Heritability of SAD has been estimated at 30 -40% meaning roughly one-third of the underlying causes of SAD come from your genetics.

Social Phobia 300. 23 DSM-IV Diagnosis (8 Criteria) 1) "A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way. . . that will be humiliating or embarrassing. " Note: "In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults. " 2) "Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. " Note: "In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations" with unfamiliar people. (American Psychiatric Association, 1994)

Social Phobia 300. 2 DSM-IV Criteria cont'd. . . 3) "The person recognizes that the fear is excessive or unreasonable. " 4) "The feared social interaction will consistently provoke distress. " 5) "Social interactions are either avoided, or painfully and reluctantly endured. " 6) "Individuals under 18 years, the duration is at least 6 months. " 7) "The fear or avoidance is not due to the direct physiological effects of a substance. " 8) "The fear or anxiety cannot be attributed to a medical disorder, substance use, or adverse medication effects or another mental disorder, and if another medical condition is present which may cause the individual to be excessively self conscious- e. g. , prominent facial scar, the fear and anxiety are either unrelated, or disproportionate. " (American Psychiatric Association, 1994)

Social Anxiety Disorder 300. 23 (Social Phobia) DSM 5 10 Criteria 1) "Fear or anxiety specific to social settings, in which a person feels noticed, observed, or scrutinized. 2) "Typically the individual will fear that they will display their anxiety and experience social rejection. " 3) "Social interaction will consistently provoke distress. " 4) "Social interactions are either avoided, or painfully and reluctantly endured. " 5) "The fear or anxiety is out of proportion to the actual threat posed by the situation and to the sociocultural context. " (American Psychiatric Association, 2013)

SOCIAL Anxiety Disorder 300. 23 (Social Phobia) DSM-5 10 Criteria Cont'd 6) "The fear , anxiety, or avoidance will is persistent for 6 months or longer. " 7) "The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ' 8) "The fear, anxiety, or avoidance cannot be attributed to the physiological effects of a substance or another medical condition. " 9)The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, autism spectrum disorder. " 10) "If another medical condition is present, the fear , anxiety, or avoidance is clearly unrelated or is excessive. " (American Psychiatric Association, 2013)

Symptoms of the Disorder People with social phobias tend to avoid eating, drinking, eye contact, and shaking hands in social situations. (American Psychiatric Association, 2013) Sometimes they may experience stuttering, shortness of breath, pounding of the heart, or blushing This may also cause them to withdraw from certain situations For example: A person may be so uncomfortable speaking in public that they do not attend an important event in order to avoid the situation

Differentiation of Symptoms DSM-IV-TR Symptoms for 6 months time frame was only required of children DSM-5 Symptoms must be persistent, lasting 6 months or longer for adults also Required that the individual recognize that their response is excessive or unreasonable Shifts this judgment to the clinician For children Includes severe, prolonged crying, tantrum, becoming physically immobilized, shrinking away from people For Children: Added extreme clinging and not being able to speak in social situations. ( all 6 behaviors can occur as a reaction to people the child knows or to strangers.

Sub-Classifications DSM-IV included the specification of generalized social phobia, when a person is afraid of "most social situations. " (American Psychiatric Association, 1994) DSM-5 only mentions the sub classification of performance only social anxiety disorder Affect professional lives and situations involving public speaking (APA, 2013) Other studies suggest the existence of speaking only phobia and complex social phobia, which is fear of various social interactions (Stein & Chavira, 1998)

Degrees of Impairment /Severity Impairment is a criteria of social anxiety disorder Must interfere with the clients daily life Including "occupational or academic functioning, or social activities or relationships" or cause the client problems "in social, occupational, or other important areas of functioning" (APA, 2013) Example: If a client fears eating in public, but is not currently not bothered by this phobia and eats at home, they would not be classified as having social anxiety disorder

Differential Diagnosis For Social Phobias Normative shyness Agoraphobia Panic disorder Generalized anxiety disorder Separation anxiety disorder Specific phobias Selective mutism Major depressive disorder

Differential Diagnosis Body dysmorphic disorder Delusional disorder Autism spectrum disorder Personality disorders Other mental disorders Other medical conditions Oppositional defiant disorder Cont'd

Social Phobia You. Tube video

Prevalence of the Disorder Culture Social phobias are found all over the world Social phobias are highly prevalent in Western society. It's estimated that 10 -13% of the western society population suffer from social phobia, while only 0. 4 -0. 6% of eastern society population suffer from SP. It is possible, however, that the prevalence of phobias within the Asian culture is significantly misrepresented. Social phobia presents differently in other societies in Eastern societies social phobia is looked upon as egocentric, whereas eastern societies manifest as allocentric (other-orientated). It is suggested these differences are heavily influenced by culture.

Prevalence of the Disorder Socio-economic status Studies are limited on the socio economic status and the impact phobias have economically on the individual. Some studies reports people in lower economic groups tend to have higher rates of phobias reported. Studies also show higher drug use and lower rates of employment for those who have been diagnosed with phobias. Depending on the nature of the phobia, and the severity, the phobia can have a direct impact on an individuals income and quality of life. Treatment for phobias are highly dependent on the areas the individual lives and the access or availability, for low income individuals who are unable to afford treatment are more likely to suffer and remain in poverty.

Prevalence of the Disorder Gender More women are found to suffer from social phobias than men. In a study of 8, 000 participants, 11. 1% of men reported a diagnosis of social phobia, while 15. 5% of women reported it. While women are more likely to receive a diagnosis of social phobia, an equal amount of women and men are shown to receive treatment. Some researchers suggest that the expectation of traditional gender roles is a contributing factor in the development and manifestation of social phobia. ex. shy boys are less likely to behave in a traditional "manly" behavior and more likely to experience negative emotions and conflict in public. In one study of 41 patients, 43% of women feared others might view them as "crazy, " compared to 15% of the men.

Prevalence of the Disorder Age Two most common periods of onset of social phobia was during adolescents (14 -17) and early childhood (prior to age 10). Social phobia onset after these period are uncommon, and usually paired with another mental illness diagnosis. . . such as depression, eating disorders, or psychosis. ) Prevalence rates decline with age, with the prevalence rates in older adults being 2 -5%. Social phobia in children can be demonstrated by crying, clinging to a familiar person, wariness. Social phobias in adolescents and adults can be demonstrated by panic like symptoms.

Prevalence of the Disorder Race In the united states, American Indians have shown a high rate of social phobia diagnosis. While Asians, Latinos, African Americans, and Afro-Caribbean decent compared with non-Hispanic whites.

Prevalence of the Disorder Sexual Orientation No research available in the prevalence or correlation of social phobia and sexual orientation.

Prevalence of the Disorder Impact Social phobia can cause impairment of quality of life. Some studies report that smokers who suffer from social phobia reduce the degree of anxiety when smoking. Increasing health risks. People who suffer from Social Phobia have an increased risk of depression. Women having the odds of 1: 6. No direct information about the impact social phobia has on at-risk populations, however, women have higher rates of social phobia, American Indians have the highest rate of social phobia among other races within the United States. Social Phobia is more likely to manifest in early childhood or adolescents. All of these factors indicate that social phobia impacts at risk populations at a greater rate then non-at risk populations.

Historical Overview of the Disorder Social phobias were first recognized long ago. This disorder dates back to 400 B. C. Social Phobia is also referred to as social anxiety and is described by some as extreme shyness, anxiety and fear. Psychologists used the term “social neurosis” or avoidant personality disorder prior to social phobia, and generalized anxiety disorder.

Historical Overview of the Disorder Continued In the third edition of the DSM-III, social phobia was included as an official psychiatric diagnosis. Although social anxiety disorder has only been officially recognized since 1980, the problem did not become more fully explained until the 1987 version of the DSM.

Historical Overview of the Disorder Continued Non-Therapeutic Approaches Hydropathy Therapeutic Approaches CBT Counseling Zoloft Effexor Paxil Beta-Blockers Herbs and Balms Bloodletting Bathing in freezing temperatures

Effectiveness of CBT in treating Social Phobias Cognitive therapy has proven very beneficial and teaches patients to understand how their thoughts contribute to the symptoms of anxiety disorder and how to change their thought patterns. Combined with behavioral techniques to help confront scary situations, therapy assists a patient to feel safe in their environment.

Evidence-Based Practice Long-term Outcomes of Social Phobia Treated by Exposure

Purpose of Research The goal of the study was to provide long term follow-up of patients with social phobia who were successfully treated by exposure therapy alone There is a lack of long-term follow-up studies, specifically over 2 years Study hoped to answer the following questions -What is likelihood of relapse after 2 years for patients who have been remitted? - Any variables that may predict long-term outcomes?

Demographic Information This study started off with 54 patients who completed treatment and of those 45 were said to be remitted Of the 45 -17 were male, 28 were female -29 were considered middle/upper class, 16 were working class -35 had over 13 years of education, 10 had less than 13 years of education -11 used benzodiazepines, 34 did not -8 used antidepressant drugs, 37 did not -10 had some form of personality disorder

CBT Intervention Used The CBT intervention that was used in this study was exposure therapy The treatment consisted of 8 sessions that were 30 minutes long and occurred once every 2 weeks The exposure treatment plan was designed collaboratively with patient and therapist Patients were asked to re-enter there phobic situation and remain there despite feelings of anxiety arising. These exposures were recorded in a structured diary by the patient and therapist would provide feedback during the sessions When treatment was complete, patients were tested by an outside clinical psychologist

Results 6 out of 45 patients had a relapse social phobia during the follow up The 6 patients who relapsed were offered a new course of exposure therapy treatment. 4 patients recovered at the end of that treatment. The estimated cumulative percent of patients that remained in remission was -98% after 2 years -85% after 5 years -85% after 10 years The results show that the use of exposure therapy with social phobia does have long-term effects

Results Continued 2 patients (4%) developed major depressive episode. This small number is inconsistent with other studies where there is a strong risk for patients with social phobia to develop major depression The study found that age, sex, duration of illness and co-morbidity of anxiety and depressive disorders did not predict outcome Three risk factors were clinically significant -presence of a personality disorder -level of residual social phobia after treatment - use of benzodiazepines

Recommendations The author did not make any recommendations but it did make note that this was the longest duration of follow up in literature of social phobia The author also pointed out that a limitation of the study is that it excluded individuals who had concurrent major depression, agoraphobia and obsessivecompulsive disorder. The inclusion of these individuals was said to have yielded more favorable results. This may be an area of future research It was also noted within the article that 1 out of 3 patients is unable to complete treatment or does not benefit from it. Future research could address why that is.

Critical Analysis The main strength of this study is that it shows long-term results of exposure therapy with social phobia and is the only one of its kind A limitations of the study is that it excluded a group of individuals (individuals with major depression, agoraphobia and obsessive compulsive disorders who required certain treatment protocols) A second limitation is that the treatment was performed by highly experienced therapists. This could have positively affected the results A third limitation is the study's size. Although this study required long term follow up, I believe it would have benefited from having a larger sample size

Critical Analysis Continued This study was useful because it provided a better understanding of exposure therapy, exemplified its long-term effect and highlighted risk factors that are associated with relapse If I was a researcher, I would have increased the sample size and included therapists with a more diverse background. These two factors would have only strengthened the results To increase the effectiveness across various populations, I would suggest doing an additional study that included individuals who were on psychotropic drugs or other forms of treatment in addition to the exposure therapy.

References American Psychiatric Association. (1994). Desk reference to the diagnostic criteria from DSM-IV. Washington, DC. : American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed. ). Arlington, VA: American Psychiatric Association. Brooke, C. (2008). Social anxiety disorder: A review of environmental risk factors. U. S. National Library of Medicine. Retrieved from: http: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 2515922/ Cuncic, A. (2014). What are the genetic causes of social anxiety disorder? Retrieved from: http: //socialanxietydisorder. about. com/od/geneticfactors/a/genetics. htm G. A Fava, S. Grandi, C. Rafanelli, C. Ruini, S. Conti and P. Belluardo (2001). Long-term outcome of social phobia treated by exposure. Psychological Medicine, 31, pp 899 -905. doi: 10. 1017/S 0033291701004020. Stein, M. B. , & Chavira, D. A. (1998). Subtypes of social phobia and comorbidity and other anxiety disorders. U. S. National Library of Medicine. Retrieved from www. ncbi. nlm. nih. gov/pubmed/9851573

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