1. S OCIAL A NXIETY D ISORDER (S OCIAL P HOBIA ) AND S ELECTIVE M UTISM Samuel J. Eckrich, M.S. Child Psychopathology University of Central Florida

2. B ACKGROUND AND H ISTORY OF S OCIAL A NXIETY D ISORDER (S OCIAL P HOBIA ) (SAD) 400 BC : “…He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him.” –Hippocrates 1900-1950 : “Social neuroses” “Social Phobia” included in the DSM-III (1980, defined in 1987). Recognized in children in DSM-VI (1994) Renamed “Social anxiety disorder (social phobia)” in DSM-V.

3. D IAGNOSTIC C RITERIA FOR S OCIAL ANXIETY D ISORDER (S OCIAL P HOBIA ) A. 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. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

4. 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. D IAGNOSTIC C RITERIA FOR S OCIAL ANXIETY D ISORDER

5. C HANGES IN DSM-V 1) Social phobia = Social Anxiety Disorder (Social Phobia). 2) The person does not have to recognize that their fear is unreasonable/disproportionate. 3) Specifier of “Generalized” replaced with “Performance Only” due to operationalization issues.

6. A SSOCIATED F EATURES Inadequately assertive, excessively submissive Inadequate eye contact, rigid posture, overly soft voice Socially delayed- live at home longer. Seek out jobs that do not require contact (not “performance only” group. Self medication is common (adolescents) Increased heart rate. Blushing.

7. D IFFERENTIAL D IAGNOSES Pretty much everything Normative shyness, agoraphobia, panic disorder, anxiety disorder, selective mutism, separation anxiety, specific phobias, major depressive disorder, body dysmorphic disorder, delusional disorder, autism spectrum disorder, personality disorder (avoidant), eating disorders, obsessive compulsive disorder, schizophrenia, ODD, cultural norms. Children (7-12 y.o.) and Adolescents (13-17 y.o.) often have differential presentation (Rao et al., 2007) : Children have a broader general pychopathology Adolesc. have a more pervasive pattern of social dysfunction

8. A NXIETY - INDUCING SITUATIONS C HILDREN VS. A DOLESCENTS Rao, Beidel, Turner, Ammerman, Crosby, Sallee, 2007

9. P REVALENCE /A GE OF O NSET 12 month: 5-8% (Costello et al. 2003; Kessler et al. 2012; Wittchen et al. 1999). Lifetime: 7-13% which makes it the 3 rd most common psychiatric disorder (Kashdan & Herbert, 2001) Child/Adult rates are similar but typically decrease with age (Wolitzky-Taylor et al. 2010) More common in females (1.5M:2.2F), especially adolescents Lifetime ~10% for females ~5% for males (Wittchen, 1999) Higher for American Indians, and lower for Asian, Latino, African American compared to non-Hispanic white (Lewis-Fernández et al. 2010) Median age of onset is 13. 75% between 8-15. (Kessler et al. 2005).

10. R ATES OF C OMORBIDITY Any other disorder (81%) (McGee et al., 1996) Any anxiety disorders (50% ) (Wittchen et al., 1999) - Panic disorder (5-10%) - Agoraphobia (7-12%) - Specific Phobias (40-50%) -Suicide attempts (14.3%) (Cougle et al., 2009) Depressive disorders (30-50%) (Wittchen et al., 1999) Substance use disorders (35-45%) (Wittchen et al., 1999) Females: More likely to have comorbid depressive, bipolar, and anxiety disorders. Males: More likely to fear dating, have ODD, and CD, and use Substance Use Disorders. (Ruscio et al. 2008; Turk et al. 1998). * Generally difficult to ascertain because shyness is associated with other anxieties, depression, and general neuroticism. (Rapee and Spence 2004).

11. S ECONDARY D IAGNOSES FOR C HILDREN VS. A DOLESCENTS Rao, Beidel, Turner, Ammerman, Crosby, Sallee, 2007

12. S ELF R EPORT M EASURES C HILDREN VS. A DOLESCENTS

13. H ERITABILITY Moderate but significant genetic influence.31-.65 heritability estimate (anxiety disorders) (Albano et al., 1995; Beatty et al., 2012).34-.66 for behavioral inhibition (Robinson et al., 1992).48 for “shyness” and “fear of negative evaluation” (Stein et al., 2002) * Still difficult to know what is specifically attributable to SAD: high interrelationship of genetic influences on other anxieties, depression, and SUDs One study found that in a study 1198 twins, the best-fitting model indicated as much as 13% of the variance in social fears was accounted for by genetic factors unique to this type of fear. Specific genetics associated with different types of fears Stein et al., 2001a, 2001b, finds a common genetic influence for both SAD in adolescents and depression in adulthood.

14. G ENETICS RELATED TO NEUROTRANSMITTERS Repeat polymorphisms in genes associated with: Dopamine transporters (DAT) (Rowe et al. 1998) Serotonin Transporters (5-HTT) (Schmidt et al., 2002) However: There just as many studies that do not find links. (Kennedy et al., 2001, Stein et. al 1998) DAT and 5-HTT are commonly dysregulated in most psychiatric disorders Maybe Genome Wide Association studies (GWAS) will offer specificity in the near future

15. DSM-V INFORMED M ODEL Genetics Temperament Gender Environment Social Anxiety Disorder

16. E NVIRONMENTAL E TIOLOGY OF SAD Direct traumatic conditioning 92% of SAD adults had a history of teasing compared to 50% with Panic Disorder and 35% with OCD (McCabe et al., 2003) 56% of those with specific social phobias had a direct link to a traumatic event (Stemberger et al., 1995)

17. E NVIRONMENTAL E TIOLOGY OF SAD C ONT. Social Learning Theory Vicarious conditioning: Ex. Watching a classmate being humiliated in class. 13% blamed vicarious conditioning event Avoidance behavior modeling: Individuals with SAD are more likely to have parents who exhibited avoidant behavior (Rapee and Melville, 1997) Reciprocation of avoidant behavior (Barrett et al., 1996) Cultural transmission “Taijin Kyofusho” - Japanese analogue of SAD engendered by a collectivist society.

18. E NVIRONMENTAL E TIOLOGY OF SAD C ONT. Preparedness Theory (Ohman et al., 1985) Evolutionary perspective in which the dominance hierarchies that signal intrapersonal threats inherently produce fear (become CSs) Paired angry faces with mild shock and showed that that the conditioning was superior to that of happy faces. Even worked when faces were shown subliminally (Esteves et al. 1994)

19. E NVIRONMENTAL E TIOLOGY OF SAD C ONT. Perception of Uncontrollability Social defeat in animals Drug studies Uncontrollable shock increases submissiveness (Williams and Lierle, 1987) Contributes to individual differences and risk factors

20. T EMPERAMENTAL E TIOLOGY OF SAD C ONT. Behavioral Inhibition (BI) A Temperamental diathesis for SAD. Similar to Specific Phobias, underlying individual differences may account for the development of SAD Many people have traumatic experiences without ever developing anxiety. This could be due to experience, Presence of BI can reliably predict the onset of specific phobias in childhood and SAD in adolescence (Haywood et al., 1996; Kagan et al., 1997)

21. R EVIEW OF E NVIRONMENTAL R ISK F ACTORS Direct traumatic conditioning Vicarious conditioning Avoidance behavioral modeling Cultural transmission Preparedness theory (evolutionary) Perception of uncontrollability Temperamentally predisposed (Behavioral Inhibition)

22. B EHAVIORAL I NHIBITION (BI) E XPERIMENTAL D ESIGN Kagan, Reznick, and Snidman 1987. “ Hypothesis : Individual differences in behavioral reactions to threat and challenge is due to threshold differences in circuits… influenced by the hypothalamus.” Screened 400 children by phone and observation to find 60 consistently inhibited and 60 consistently uninhibited. Basically measures of shyness. Two groups of 60 equal 1M:1F. Measurements taken at 21 months, 31 months, 3.5 yr, 4 yr, 5.5yr. Unfamiliar female examiner, unfamiliar toys, separation from mother, unfamiliar peer of both sexes, classmates, cognitive tests, stressors, objects suggestive of risk (balance beams, black box with a hole). BI = latencies to interact, immediate retreat, proximity to mother, cessation of play or vocalization

23. BI PRESERVATION OF BEHAVIOR Those inhibited at 21 months were significantly correlated to those at 5.5yrs (r =.52). Likewise from 4-5.5yrs (r =.67). Latency to speak was the most sensitive measurement of BI * More preservation of uninhibited than inhibited * More boys than girls changed from inhibited to uninhibited

24. C ORTISOL

25. P HYSIOLOGICAL M EASURES Heart rate, pupil dilation, muscle tension, cortisol Neurological correlates: Limbic system, HPA, reticular activating system, nucleus ambiguous, sympathetic nervous system (norepinephrine) Cortisol was the best predictor of inhibited vs. uninhibited (78%). InhibitedUninhibited Heart Rate High and StableLow or Variable Pupil dilation Largersmaller Muscle tension Increaseddecreased Cortisol IncreasedDecreases

26. I NITIAL C ONCLUSIONS Behavioral inhibition is moderately preserved across time points and physiological measures. State of uncertainty has physiological correlations. Possibly due to different thresholds of reactivity in the amygdala and hypothalamus of inhibited vs. uninhibited children. Still, not every inhibited child stayed inhibited. Only significant when analyzed categorically, not dimensionally. Only 1/3 of the inhibited at 21mo. scored high on each measure. Experience factors? Heritability (.34-.66) is moderately high, but still missing some pieces: gender, parental temperament? Make does this mean for Social Phobia? Lifetime trajectory?

27. R ECENT B EHAVIORAL I NHIBITION S TUDIES Schwartz, Snidman, Kagan, 1999

28. R ECENT M ETA -A NALYSIS OF B EHAVIORAL I NHIBITION Clauss and Blackford, 2012 BI was associated with a greater than sevenfold increase in risk for developing SAD (Odds ratio = 7.59 ).

29. F UNCTIONAL AMYGDALA C ONNECTIVITY IN BI YOUNG ADULTS 19 high BI/19 low BI in childhood were tested at 18- 21 (Roy et al., 2014). Less functional connectivity between amygdala and striatum, pFC, insula, and cerebellum in BI.

30. R EVIEW THE R ISKS 1. Genetics (many shared genes, possibly some specific to social anxiety) 2. Environment (traumatic events, culture, experience, preparedness, parental stress) 3. Temperament (Behavioral Inactivation) 4. Physiology, brain structure, neurochemicals Genetics and Environment work together to create a temperament. That temperament is highly correlated to physiological changes specific to fear and stress circuitry in the brain. Yet, all of the variance is not assumed. Many children aren’t at the extremes of the measurements. What other distinctions may help identify at risk children?

31. S OCIAL A NXIETY AND S OCIAL C OGNITION “Biases and distortions in social-information processing and thoughts may affect attitudes and beliefs that trigger and/or maintain social phobic behaviors” (Rapee et al., 2014) Ability to understand other’s mental states Clark and McManus (2002) Social inference (TASIT) Theory of Mind (Reading Mind in Eyes Test, Faux Pas ) Identify emotions Questionnaires/Other tests Interpretation of external social events Reduced Processing of External Social Cues and Enhanced Self- Focused Attention Detection and recall of negative social cues

32. W ILLIAMS S YNDROME VS. SAD F MRI V IEWING F ACES : A META - ANALYSIS Binelli et. al., 2014

33. C OMPARISON OF C HILDREN AND ADOLESCENTS ON BEHAVIORAL ASSESSMENTS AND P ERFORMANCE S KILL Rao, Beidel, Turner, Ammerman, Crosby, Sallee, 2007 This suggests that children have generally poorer social skills which may lead to negative cycles.

34. R EVIEW THE R ISKS 1. Genetics (many shared genes, possibly some specific to social anxiety) 2. Temperament (Behavioral Inactivation) 3. Environment (traumatic events, culture, experience, preparedness, parental stress) 4. Physiology, brain structure, neurochemicals 5. Social cognition and social skills Other mediators * Gender (adolescent) * Maternal stress (Parent/child interaction)

35. T HERAPY Division 53: “Coping cat” developed by Phillip C. Kendell Children (6-13yrs) version and adolescent version (C.A.T.). Manual-based CBT treatment Participant youth are taught features of the disorder Develop a plan to cope with anxiety (“FEAR plan”). F eeling frightened E xperiencing bad things A ctions that will help R esults and rewards Provide situations to practice plans Learn cues for becoming anxious and cue for using social skills

36. T HERAPY C ONT. Social Effectiveness Therapy for Children and Adolescents (SET-C) Developed by Dr. Beidel Group social skills training Structured peer generalization sessions Individualized behavioral exposure tx.

37. P HARMACOTHERAPY SSRIs are the most studied and effective (Reinblatt et al., 2007) SNRI *Adverse: Paroxitine = 2x as much insomnia, decreased appetite, and vomiting. Venlafaximine = weight loss

38. SET-C VS SSRI Beidel et al., 2007 More efficacious than Fluoxetine (p <.025).) and placebo (p <.001) at 12 wks.

39. SET-C VS. SSRI CONT. Also: SET-C was the only treatment superior to placebo in terms of improving social skills, decreasing anxiety in specific social interactions, and enhancing ratings of social competence. But, meds are more transportable!

40. N EW D IRECTIONS Still 25-35% do not get better with any tx. (Connolly et al., 2001) Using virtual reality to treat and to assess (An Doan)

41. Neurobiological factors Genetics Traumatic events, culture, uncontrollability, preparedness, parental stress Temperament Social Anxiety Disorder Gender Social Cognition/Skills SET-C/ CBT SSRIs/ SNRIs

42. B ACKGROUND AND H ISTORY OF S ELECTIVE M UTISM 1877, German physician Adolph Kussmaul, “ aphasia voluntaria” 1980 : Added to DSM-III, “ Elective mutism ” Predisposing disorders were originally: Overbearing parents, mental retardation, and trauma. NOT connected to social phobia. DSM-IV (1994) Changed to “ Selective mutism ” and connected to anxiety disorders. DSM-V: "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" to the section for anxiety disorders.

43. D IAGNOSTIC C RITERIA FOR S ELECTIVE M UTISM (SM) A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. Diagnostic and Statistical Manual of Mental Disorders(5 th ed., 2013)

44. C HANGES IN DSM-V FOR SM 1) For children only: added “ extreme clinging ” and not being able to speak in social situations.” 2) Classified under “Anxiety Disorders.” No longer under “Disorders first diagnosed in infancy, childhood, or adolescence.

45. D IAGNOSTIC F EATURES Children will speak in their home or in front of immediate family, but not to close friends or relatives. Children with selective mutism often refuse to speak at school, leading to academic or educational impairment, as teachers often find it difficult to assess skills such as reading. Will often communicate non-verbally. May excel in non-verbal areas of school.

46. A SSOCIATED F EATURES OF SM Excessive shyness, fear of social embarrassment, social isolation and withdrawal (Carbone et al. 2010; Cohan et al. 2008) Clinging, compulsive traits, negativism, temper tantrums, or mild oppositional behavior (Cohan et al., 2008) Almost always given an additional diagnosis of another anxiety disorder—most commonly, social anxiety disorder (social phobia) (Viana et al. 2009)

47. D IFFERENTIAL DIAGNOSES Communication disorders Neuropsychiatric disorders/Schizophrenia/ Psychotic Disorders. Social Anxiety Disorder (Social Phobia)

48. P REVALENCE /A GE OF O NSET OF SM Relatively rare. 0.03 - 1% (Bergman, 2002, Viana et al., 2009, Carbone et al., 2010) 2.7 – 6.8 yrs. (Cunningham et al., 2004) Does not vary by race, sex, or ethnicity. More prevalent in children vs. adolescents or adults. Usually unrecognized until child enters school. Usually not disruptive so it can go unrecognized. Cultural issues- language barriers. Duration: Unknown. Many grow out of it but retain features of anxiety disorders throughout lifetime.

49. R ATES OF C OMORBIDITIES FOR SM 1. Other anxiety disorders (60-97%) (Kristensen, 2001) - SAD (44-100%; odds 1.6-8 ) (Anstendig,1999; Vecchio and Kearney, 2005; Arie et al., 2006; Manassis et al. 2007) - Avoidant personality disorder (17-30%) (Chavira et al., 2007) - SAD, avoidant disorder, or both (97%) (Black & Uhde, 1992) - Separation Anxiety (17-31.5%) (Black & Uhde, 1992; Kristensen, 2000) - Specific Phobia (30-50%) (Manassis et al., 2003) 2. Externalizing disorders - ADHD (11.1%) (Arie et al., 2006) - ODD (6.8%) (Manassis et al., 2007) 3. Other disorders - Enuresis (17-30%) (Black and Uhde, 1995; Kristensen 2000) - Encopresis and tic disorder (7%) (Kristensen 2000) - Phonological disorder (40%) (Kristensen 2000) -Other language disorder (11.5-17.3) (Kristensen 2000)

50. SM, AN E XTREME VARIANT OF SAD? Children with SM compared to children with another anxiety disorder are generally rated the same on internalizing measures, general anxiety, and social anxiety. (Vecchio and Kearney, 2005) Age of onset is usually younger SAD kids have higher reported anxiety levels, but the differences are most likely a result of behavioral avoidance leading to underreporting of symptoms in SM kids (Kristensen, 2001; Melfsen et al, 2006; Viana et al., 2009) SM may be more akin to severe avoidance behavior. SM kids most likely have anxiety. It may not matter how to categorize because they respond equally to similar therapy/ Tx.

51. E VIDENCE FOR SM AS AN A NXIETY D ISORDER Determining etiology is difficult (biased parental report, teacher, etc.) regarding core fear. Large studies are difficult to do given the rarity. Few objective data that determine the presence of emotional arousal Scott and Beidel, 2011

52. E VIDENCE FOR SM AS AN A NXIETY D ISORDER Children with SM report similar levels of anxiety as children with SP (Yeganeh et al., 2006) Emotional Regulation Theory Intensity, duration, and expression of anxiety dysfunctional Becoming selectively mute is a developmental mechanism employed in order to avoid extreme emotional arousal

53. E TIOLOGY OF SM Genetic Concordance rates = Mothers (18%); Fathers (9%); Siblings (18%) (Remschmidt et al., 2001) Parents more often than controls have Social anxiety and “ shyness ” (Remschmidt et al., 2001) Mothers more often have other psychopathology (personality disorders, avoidance, shyness, withdrawal) (Chavira et al., 2007) Family Dysfunction/Poor Reinforcement Strategy Creates an environment that promotes dysfunction Model anxious behavior/limit social interaction Reinforce avoidance behavior Behavioral Inhibition

54. C OMMUNICATION DISORDER SM SM typically do worse on nonverbal communication tests than SAD kids (Manassis et al., 2003) Difficult to ascertain due to temporal issues May be mute due to language difficulties Also, the muteness may develop into language difficulties Similarly dysfunctional to SAD kids in social skills, communication skills, and classroom achievement (Carbone et al., 2010)

55. T RAJECTORY FOR SM Most grow out of it. Almost all transfer some of the maladaptive social skills into adolescents and adulthood (Joseph et al., 1999; Remschmidt et al., 2001) The more the behavior is reinforced, the more rigid and resilient it becomes. Most likely an active way to decrease arousal, but shouldn’t be considered oppositional (Scott and Beidel 2011)

56. The END

57. R EFERENCES

61. S UPPLEMENTAL C OMPARISON OF T HERAPIES CBT vs. Psychodynamic; Bogels et al., 2014. Both therapies showed clinically significant improvements as shown by reliable change index. Posttest = 64% of CBT and 63% of PDT; 3 mo. = 58 %, 50 % No longer meeting diagnostic criteria, scoring below SPAI cutoff. Still, social validity should be evaluated.

63. Pituitary/Adre nal Amygdala Hypothalamus Reticular activating system Cortisol Norepinephrine Pupil dilation, heart rate, muscle constriction

64. B AD A SS N EW M ODEL

65. H ERITABILITY OF BI Robinson, Resnick, Kagan, Corley, 1992

66. A NEW M ODEL Essex et al., 2010 Takes into account maternal stress and gender

67. S OCIAL C OGNITION M ODEL FOR S OCIAL A NXIETY D ISORDER “I must always sound Intelligent” leads patients to appraise situations as dangerous which generates anxiety. “The anxiety and negative appraisal are maintained in a vicious cycle.” (Clark and McManus 2002)