Social Anxiety Disorder: Overview

Social Anxiety Disorder: WHO?
In the general population, the number of female with SAD is higher than the number of male with SAD.1 However, clinical samples show equal or higher rate of male with SAD than female with SAD. The frequency of male with SAD is underreported in general population, and it is believed that it is the gender role assumption and social expectation on male that lead to their reluctance to seek for help for their condition.
In the U.S., SAD is found to be affecting 7.1% of the population.7 On the other hand, studies conducted in East Asia found a lower prevalence rate of SAD, for example 0.8 in Japan8, 0.2% in China9, and 0.3% in Korea10.
Interestingly, there is a special manifestation of SAD which is more prevalent in Japan and Korea that is known as Taijin Kyofusho (TKS) (対人恐怖症).11 Individual with TKS displays symptoms of intense anxiety about being observed by others which leads to the avoidance of social situations. One major different of TKS from typical SAD is that individual with TKS is more concern on their action might offend or embarrass other people, while individual with typical SAD is more concern on embarrassing themselves.

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Adapted from: //www.humanosphere.org/wp-content/uploads/2013/06/AfghanistanDepression.png

Social Anxiety Disorder: HOW?
Over the years, extensive studies have focused on discovering efficacious and effective treatment for SAD. Cognitive behavioural therapy (CBT) is one of the well-researched treatments supported by scientific evidence for individuals with SAD.12 In CBT, practitioners aim to help clients overcome the fear and anxiety symptoms in social situation and change the beliefs that are maintaining the behaviour.13 Different techniques would be systematically implemented to modify the current behavioural repertoires of the individual with SAD. Some examples of the techniques are:
1. Applied relaxation14: A technique of replacing previous conditioned response (fear) with new conditioned response (relaxation). Client would be taught on progressive muscle relaxation (PMR) that can be used to manage physiological arousal elicited by anxiety. Once mastered, client would be exposed to anxiety-provoking social situation (graduated exposure) and practice PMR when they are anxious.
2. Graduated exposures2: A process of repeatedly and gradually exposing clients to the feared social situation to abate the conditioned anxiety. To use this method, practitioner and client first build a fear and avoidance hierarchy. The feared social situation is ranked based on the degree of anxiety they elicit. Exposure often begins with lower-ranked social situation (situation that triggers less fear and anxiety). Once client has habituated and felt less anxious towards the situation, the client can move up the hierarchy to higher-ranked social situation (situation that triggers more fear and anxiety), and eventually to the social situation that creates most anxiety.

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Adapted from: //www.brunet.ca/userfiles/image/conseils/sante/maladies-mentales/6_CHOSES_A_SAVOIR_SUR_LE_TAG-big.jpg

3. Cognitive restructuring2: An approach of altering client’s dysfunctional beliefs about the feared social situation. In this approach, practitioner work with client to identify the negative beliefs (e.g. “Everyone will laugh at me when I talk”) and replace them with more rational, adaptive beliefs (e.g. “Look at the audience. How many of them are actually laughing at you?”).
Another option of SAD treatment is pharmacological treatment. Different medications have been explored; some showed inconsistent findings, while others produce good results but was associated with some limitations. Up to date, the use of selective serotonin reuptake inhibitors (SSRI) (e.g. escitalopram, sertraline) is recommended and has showed consistent efficacy for individuals with SAD.15,16
Although both CBT and pharmacological treatment were shown to be effective for SAD, there is inadequate evidence to conclude the combination of both treatment yield better outcome.17 When the treatment is implemented independently, pharmacological treatment seems to result in more rapid improvement, but CBT may lead to enduring outcome with less risk of relapse.18

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Adapted from: //healanxiety.net/wp-content/uploads/2016/08/CBT.jpg

Social Anxiety Disorder: Closing Note
SAD is a chronic condition that often gets unrecognized. Unlike normative shyness, which is a personality trait, SAD might adversely affect a person’s life. Unfortunately, individuals with SAD tend to avoid seeking for help, which might leads to increased SAD severity, comorbid mental disorders (e.g. general anxiety disorder, alcohol abuse, major depressive disorder), and higher risk of suicide.13 Seeking for help is a hard, yet important step. I will end this article with a statement by Ricky Williams, a famous American football player, who was diagnosed with SAD and has made great progress after receiving treatment. “I understand that a lot of people, especially men, look up to me because of my profession, so I have a chance to reach out to people and let them know what I’ve been through and how treatment has made my life so much better. If my story can help even one person to seek help, it will feel as though I’ve scored the game-winning touchdown.”
To read more about personal experience of individual with SAD:

//www.adaa.org/living-with-anxiety/personal-stories/ricky-williams-story-social-anxiety-disorder (Ricky Williams’s story)
//www.adaa.org/living-with-anxiety/personal-stories

References:
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
2. Leahy, R. L., McGinn, L. K., & Holland, S. J. (2012). Treatment plans and interventions for depression and anxiety disorders. New York: Guilford Press.
3. Zakri, H. (2015). Social anxiety disorder. InnovAiT: Education and inspiration for general practice, 8(11), 677-684, doi:10.1177/1755738015601449.
4. Phan, K. L., Fitzgerald, D. A., Nathan, P. J., Tancer, M. E. (2006). Association between amygdala hyperactivity to harsh faces and severity of social anxiety in generalized social phobia. Biological Psychiatry, 59(5), 424–429.
5. Merikangas, K. R., Lieb, R., Wittchen, H. U., & Avenevoli, S. (2003). Family and high-risk studies of social anxiety disorder. Acta Psychiatrica Scandinavica, 108(417), 28-37.
6. Brook, C. A., & Schmidt, L. A. (2008). Social anxiety disorders: A review of environmental risk factors. Neuropsychiatric Disease and Treatment, 4(1), 123-143.
7. Kessler, R. C., Chiu, W. T., Demler, O., Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 617-627.
8. Kawakami, N., Takeshima, T., Ono, Y., Uda, H., Hata, Y., Nakane, Y., …Kikkawa, T. (2005). Twelve-month prevalence, severity, and treatment of common mental disorders in communities in Japan: Preliminary findings from the World Mental Health Japan Survey 2002– 2003. Psychiatry and Clinical Neuroscience, 59(4), 441–452.
9. Shen, Y. C., Zhang, M. Y., Huang, Y. Q., He, Y. L., Liu, Z. R., Cheng, H., …Kessler, R. C. (2006). Twelvemonth prevalence, severity, and unmet need for treatment of mental disorders in metropolitan China. Psychological Medicine, 36(2), 257–267.
10. Cho, M. J., Seong, S. J., Park, J. E., Chung, I., Lee, Y. M., Bae, A., …Hong, J. P. (2014). Prevalence and correlates of DSM-IV mental disorders in South Korean adults: The Korean Epidemiologic catchment area study 2011 (KECA-2011). Psychiatry Investigations, 12(2), 164-170.
11. Hofmann, S. G., Asnaani, M. A., & Hinton, D. E. (2010). Cultural aspects in social anxiety and social anxiety disorder. Depression and Anxiety, 27(12), 1117-1127. doi:10.1002/da.20759
12. Ponniah, K., & Hollon, S. (2007). Empirically supported psychological interventions for social phobia in adults: A qualitative review of randomized controlled trials. Psychological Medicine, 38(01). doi:10.1017/s0033291707000918
13. Boer, J. A. (2000). Social anxiety disorder/social phobia: Epidemiology, diagnosis, neurobiology, and treatment. Comprehensive Psychiatry, 41(6), 405-415. doi:10.1053/comp.2000.16564
14. Öst, L. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25(5), 397-409. doi:10.1016/0005-7967(87)90017-9
15. Ameringen, M. A., Lane, R. M., Walker, J. R., Bowen, R. C., Chokka, P. R., Goldner, E. M., . . . Swinson, R. P. (2001). Sertraline Treatment of Generalized Social Phobia: A 20-Week, Double-Blind, Placebo-Controlled Study. American Journal of Psychiatry, 158(2), 275-281. doi:10.1176/appi.ajp.158.2.275
16. Kasper, S., Stein, D. J., Loft, H., & Nil, R. (2005). Escitalopram in the treatment of social anxiety disorder: Randomised, placebo-controlled, flexible-dosage study. The British Journal of Psychiatry, 186(3), 222-226. doi:10.1192/bjp.186.3.222
17. Davidson, J. R., Foa, E. B., Huppert, J. D., Keefe, F. J., Franklin, M. E., Compton, J. S., …Gadde, K. M. (2004). Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Archives of General Psychiatry, 61(10), 1005-1013.
18. Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social anxiety disorder. Clinical Psychology Review, 24(7), 883-908.

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