Download Social Anxiety Disorder (SAD)

Definition:
The fundamental feature of social anxiety
disorder is the marked and persistent fear of
social or performance situations in the
presence of unfamiliar people or when
scrutiny by others is possible, even in the
context of small groups. Exposure to such
social and performance situations almost
invariably provokes an immediate anxiety
response or avoidance behavior.
Ibtihal M.A. Ibrahim
Associated features of social
anxiety disorder
poor social skills
negative
evaluation
difficulty of
being assertive
Ibtihal M.A. Ibrahim
hypersensitivity
to criticism
low self-esteem
and feelings of
inferiority
The most frequent social trigger situations are
initiating or
maintaining
conversation
participation in
small groups
interacting
with people in
authority
attending
parties
writing or
performing in
front of others
eating or
drinking in
public
using public
toilet facilities
dating
somebody
Ibtihal M.A. Ibrahim
• simple performance anxiety, stage
fright, as well as shyness in social
situations should not be diagnosed
as social anxiety disorder unless
the anxiety and avoidance are
marked and persistent and lead to
clinically significant impairment or
subjective suffering in a systematic
way whenever exposed.
It is important
to note that:
Ibtihal M.A. Ibrahim
Social Anxiety or Shyness
• Shyness is a term used to describe the feeling
of apprehension, lack of comfort, or
awkwardness experienced when a person is in
proximity to, especially in new situations or
with unfamiliar people.
• Shyness may come from genetic traits, the
environment in which a person is raised and
personal experiences. There are many degrees
of shyness.
Ibtihal M.A. Ibrahim
Social Anxiety or Shyness
Social anxiety disorder has been portrayed as the extreme of
shyness. Shyness is more likely to be a lifelong
characteristic of an individual’s temperament, whereas
social anxiety disorder is characterized by a group of
coexisting symptoms that might be independent of
shyness.
Evidence to support the distinction between shyness and
social anxiety disorder comes from developmental
studies. Shy children who were followed over several
years from the first school years through to early
adolescence were not at an increased risk for developing
social anxiety disorder. Shyness is usually present in all
social situations while social anxiety may be triggered by
very specific situations.
Ibtihal M.A. Ibrahim
Epidemiology:
It is the third most common psychiatric disorder, with a lifetime
prevalence of approximately 13% of the general population
The average age of
onset is mid-adolescence, but the disorder occurs in children as young as age eight
Social anxiety disorder occurs in females nearly twice as often as males, although men are more
likely to seek help
The prevalence of social phobia appears to be increasing among white, married, and
well-educated individuals.
Because of the difficulty in separating social phobia from poor social skills or shyness ,
some studies have a large range of prevalence.
Ibtihal M.A. Ibrahim
DSM-IV Diagnostic Criteria:
A. 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 (or show anxiety symptoms) that will be humiliating or embarrassing.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the
form of a situationally bound or situationally predisposed panic attack.
C. The person recognizes that the fear is excessive or unreasonable.
D. The social or performance situation is avoided or else is endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s)
interferes significantly with the person's normal routine, occupational (or academic) functioning, or
social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a substance or a general
medical condition and is not better accounted for by another mental disorder.
H. If a general medical condition or another mental disorder is present, the fear in Criterion A is
unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting
abnormal eating behavior in anorexia nervosa or bulimia nervosa.
Ibtihal M.A. Ibrahim
For diagnostic purposes, SAD has
been divided in two subtypes:
• The specific subtype (sSAD):refers to the fear
and avoidance of a particular performance
situation such as public speaking. Indeed, this
is frequently the most symptom-provoking
social situation in specific SAD.
• Generalized SAD (gSAD):patients, in turn, fear
and avoid a wide array of social situations,
and are consequently more impaired than
patients suffering from specific SAD
Ibtihal M.A. Ibrahim
Ibtihal M.A. Ibrahim
Cognitive
Physiological
Behavioral
Ibtihal M.A. Ibrahim
Cognitive symptoms:
prior to the potentially anxiety-provoking social
situation, sufferers may deliberately go over what
could go wrong and how to deal with each unexpected
case.
They experience dread over how they will be
presented to others. They may be overly selfconscious, pay high self-attention after the activity, or
have high performance standards for themselves.
After
After the event, they may have the perception they
performed unsatisfactorily. Consequently, they will
review anything that may have possibly been
abnormal or embarrassing.
Ibtihal M.A. Ibrahim
Before
Event
Behavioral symptoms:
Escape
Controlled
by
Major
avoidance
behaviors
Minor
avoidance
behaviors
avoidance
behaviors
Ibtihal M.A. Ibrahim
Physiological symptoms:
children
with social
anxiety may
display
tantrums,
weeping,
clinging to
parents
Blushing
sweating
The walk
disturbance
nausea
stomach
ache
shaking
Mind go
blank
palpitations
Ibtihal M.A. Ibrahim
Ibtihal M.A. Ibrahim
Biological
• Genetic and family
factors
• Neural
mechanisms.
• Neuroanatomical.
Psychological
Social
Ibtihal M.A. Ibrahim
• Cognitive context.
• Evolutionary context.
• Social
experiences
• Social/cultural
influences
Genetic and family factors:
• It has been shown that there is a 2-3 folds greater
risk of having social phobia if a first-degree relative
also has the disorder.
• This could be due to genetics and/or due to
children acquiring social fears and avoidance
through processes of observational learning.
• Studies of identical twins brought up (via
adoption) in different families have indicated that,
if one twin developed social anxiety disorder, then
the other was between 30 – 50% more likely than
average to also develop the disorder.
Ibtihal M.A. Ibrahim
Neural mechanisms:
Hormones
and
neuropeptid
es
Oxytocin,
Vasopressin,
CRF and Cortisol
Other
neurotrans
mitters
Serotonin
Norepinephrine
and Glutamate.
GABA
Dopamine
Ibtihal M.A. Ibrahim
Sociability is closely tied to
dopamine neurotransmission
Neuroanatomical:
Amygdala
involved in the
experience of
physical pain, also
appears to be
involved in the
experience of
'social pain'
Anterior
cingulate
cortex
Ibtihal M.A. Ibrahim
•related to fear
cognition and
emotional
learning.
•hypersensitive
amygdala.
Cognitive Context:
• Research has indicated the role of 'core'
or 'unconditional' negative beliefs (e.g. I
am inept) and 'conditional' beliefs
nearer to the surface (e.g. If I show
myself, I will be rejected). They are
thought to develop based on
personality and adverse experiences
and to be activated when the person
feels under threat.
Ibtihal M.A. Ibrahim
Ibtihal M.A. Ibrahim
Specific
disposition
s to
monitor
and react
to social
threats
Ibtihal M.A. Ibrahim
in modern day society
evolutionary explanation
of anxiety
in-built
'fight or
flight'
system
vital and complex
importance of social living
Evolutionary context:
tendencies can
become more
inappropriatel
y activated
and result in
some of the
cognitive
'distortions'
Social experiences:
Person with
increased
interpersonal
sensitivity
Specific
humiliating
social
event
Specific social
phobia
longer-term effects of
not fitting in
observing or hearing
or verbal warning
Ibtihal M.A. Ibrahim
Social/cultural influences:
• Society's attitude towards shyness and avoidance, affects
the ability to form relationships or access employment or
education.
• In China, research has indicated that shy-inhibited
children are more accepted than their peers and more
likely to be considered for leadership and considered
competent, in contrast to the findings in Western
countries.
• lower rates of social anxiety disorder in Mediterranean
countries and higher rates in Scandinavian countries, and
it has been hypothesized that hot weather and high
density may reduce avoidance and increase interpersonal
contact.
Ibtihal M.A. Ibrahim
Ibtihal M.A. Ibrahim
Axis I
Axis II
• Other anxiety disorders.
• Depression.
• Bipolar disorder.
• Substance use disorders.
• Eating disorders.
• Avoidant personality
disorder (APD).
Ibtihal M.A. Ibrahim
A
four
or
more
Avoids
occupationa
l activities
V
Restrains
from intimate
relationships
Views self as
socially inept
O
Occupied
with being
criticized or
rejected
Avoidant
personality
disorder is in
many ways
equivalent to
pathologic
shyness
I
R
pervasive
pattern of social
inhibition and
hypersensitivity
to negative
evaluation
Inhibited in
new
interpersonal
situations
Denies to get
involved with
people
Ibtihal M.A. Ibrahim
Embarrassed
by engaging
in new
activities
D
E
Avoidant
Personality
Disorder
Ibtihal M.A. Ibrahim
Pharmacotherapy
Psychotherapy
Combination
Ibtihal M.A. Ibrahim
Ibtihal M.A. Ibrahim
MAOIs
Benzodiazepines
SSRIs
SNRIs
β- Blocker
Ibtihal M.A. Ibrahim
Pharmacologic Treatment of Social Phobia
Drug
Starting
Dosage
Daily Dosing
Range
Maximum
Dosage
Common Side Effects
Imipramine
50 mg at bedtime
100–250 mg
250 mg
Dry mouth, blurred vision, constipation,
urinary hesitancy, orthostasis, somnolence,
anxiety, sexual dysfunction
Phenelzine
15 mg twice daily
30–90 mg
90 mg
Dry mouth, drowsiness, nausea,
anxiety/nervousness, orthostatic
hypotension, myoclonus, hypertensive
reactions
Paroxetine
20 mg
20–40 mg
60 mg
Nausea, diarrhea, anxiety/nervousness,
sexual drysfunction, somnolence
Fluoxetine
20 mg
20–60 rug
80 mg
Nausea, diarrhea, anxiety/nervousness,
sexual dysfunction
Sertraline
50 mg
50–150 mg
200 mg
Nausea, diarrhea, anxiety/nervousness,
sexual dysfunction
–
–
Somnolence, ataxia, memory problems,
nausea, physical dependence, withdrawal
reactions
10–40 mg as needed
240 mg/day
Drowsiness, headache, orthostatic
hypotension, bradycardia, exacerbation of
asthma or obstructive pulmonary disease
Benzodiazepines –
(various)
Propranolol
10 mg as needed
Ibtihal M.A. Ibrahim
Ibtihal M.A.
Ibrahim
Ibtihal M.A. Ibrahim
Social skills
training
Applied
relaxation
Exposure
Cognitive
restructuring
CBT
Cognitive
Behavioral
Group Therapy
(CBGT)
Ibtihal M.A. Ibrahim
Exposure:
creation of a fear and
avoidance hierarchy which
acts as a roadmap for
exposure practice.
stay in the feared situation,
with the expectation that an
exposure of sufficient length
will produce new learning or
habituation
exposures begin with lowerranked situations (e.g.,
moderately anxietyprovoking) and move up
gradually
performed both in and out
of session
Ibtihal M.A. Ibrahim
Applied relaxation:
Progressive muscle relaxation (PMR) is a
well-known
technique
for
the
management of the physiological arousal
that often accompanies anxiety.
PMR alone is generally accepted as
insufficient as a treatment for social
anxiety disorder, and we know of no
evidence that counters this consensus.
Ibtihal M.A. Ibrahim
Social skills training:
Modeling
NB: people
with social
anxiety
disorder may
possess
adequate
social skills
Behavioral
rehearsal
Corrective
feedback
inevitably
involves
exposure to
feared situations
Positive
reinforcement
Ibtihal M.A. Ibrahim
Cognitive restructuring:
In cognitive restructuring, individuals are taught
to:
Identify
negative
thoughts
Evaluate the
accuracy of
their thoughts
Ibtihal M.A. Ibrahim
Derive rational
alternative
thoughts
Cognitive-Behavioral Group
Therapy:
6
patients
2.5
hours
12
weeks
1&2
sessions
rationale
instructio
ns
Ibtihal M.A. Ibrahim
Predictors of treatment
response to CBT:
1.Expectancy for improvement.
2.Homework compliance.
3.Subtype of social anxiety
disorder
and
avoidant
personality disorder.
4.Axis I comorbidity.
5.Anger.
Ibtihal M.A. Ibrahim
Ibtihal M.A. Ibrahim