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Social Anxiety Disorder (S.A.D) Ass. Lecturer Psychiatry Department

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1 Social Anxiety Disorder (S.A.D) Ass. Lecturer Psychiatry Department
By Dr. Ibtihal Mohamed Aly Ass. Lecturer Psychiatry Department

2 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

3 Ibtihal M.A. Ibrahim Associated features of social anxiety disorder
poor social skills negative evaluation difficulty of being assertive hypersensitivity to criticism low self-esteem and feelings of inferiority Ibtihal M.A. Ibrahim

4 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

5 It is important to note that:
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. Ibtihal M.A. Ibrahim

6 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

7 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

8 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

9 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

10 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

11 Clinical Picture Ibtihal M.A. Ibrahim

12 Symptoms Cognitive Physiological Behavioral Ibtihal M.A. Ibrahim

13 Cognitive symptoms: Event Before After Ibtihal M.A. Ibrahim
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 self-conscious, pay high self-attention after the activity, or have high performance standards for themselves. After the event, they may have the perception they performed unsatisfactorily. Consequently, they will review anything that may have possibly been abnormal or embarrassing. Event After Ibtihal M.A. Ibrahim

14 Major avoidance behaviors Minor avoidance behaviors
Behavioral symptoms: Escape avoidance behaviors Controlled by Major avoidance behaviors Minor avoidance behaviors Ibtihal M.A. Ibrahim

15 Physiological symptoms:
Blushing Mind go blank stomach ache The walk disturbance sweating palpitations shaking nausea children with social anxiety may display tantrums, weeping, clinging to parents Ibtihal M.A. Ibrahim

16 Etiology Ibtihal M.A. Ibrahim

17 Social/cultural influences
Biological Genetic and family factors Neural mechanisms. Neuroanatomical. Psychological Cognitive context. Evolutionary context. Social Social experiences Social/cultural influences Ibtihal M.A. Ibrahim

18 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

19 Other neurotransmitters Hormones and neuropeptides
Neural mechanisms: Dopamine Other neurotransmitters Hormones and neuropeptides Oxytocin, Vasopressin, CRF and Cortisol Serotonin Norepinephrine and Glutamate. GABA Sociability is closely tied to dopamine neurotransmission Ibtihal M.A. Ibrahim

20 Neuroanatomical: related to fear cognition and emotional learning.
hypersensitive amygdala. Amygdala Anterior cingulate cortex involved in the experience of physical pain, also appears to be involved in the experience of 'social pain' Ibtihal M.A. Ibrahim

21 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

22 Ibtihal M.A. Ibrahim

23 Evolutionary context:
evolutionary explanation of anxiety in-built 'fight or flight' system vital and complex importance of social living Specific dispositions to monitor and react to social threats in modern day society tendencies can become more inappropriately activated and result in some of the cognitive 'distortions' Ibtihal M.A. Ibrahim

24 Social experiences: Specific social phobia
Specific humiliating social event Person with increased interpersonal sensitivity Specific social phobia longer-term effects of not fitting in observing or hearing or verbal warning Ibtihal M.A. Ibrahim

25 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

26 Co-morbidity Ibtihal M.A. Ibrahim

27 Ibtihal M.A. Ibrahim Axis I Other anxiety disorders. Depression.
Bipolar disorder. Substance use disorders. Eating disorders. Axis II Avoidant personality disorder (APD). Ibtihal M.A. Ibrahim

28 Avoidant Personality Disorder
pervasive pattern of social inhibition and hypersensitivity to negative evaluation Avoids occupational activities Restrains from intimate relationships Embarrassed by engaging in new activities Denies to get involved with people Inhibited in new interpersonal situations Occupied with being criticized or rejected Views self as socially inept A V R four or more O E Avoidant personality disorder is in many ways equivalent to pathologic shyness Avoidant Personality Disorder I D Ibtihal M.A. Ibrahim

29 Treatment Ibtihal M.A. Ibrahim

30 Psychotherapy Combination Pharmacotherapy Ibtihal M.A. Ibrahim

31 Pharmacotherapy Ibtihal M.A. Ibrahim

32 MAOIs Benzodiazepines SSRIs SNRIs β- Blocker Ibtihal M.A. Ibrahim

33 Benzodiazepines (various)
Pharmacologic Treatment of Social Phobia Common Side Effects Maximum Dosage Daily Dosing Range Starting Dosage Drug Dry mouth, blurred vision, constipation, urinary hesitancy, orthostasis, somnolence, anxiety, sexual dysfunction 250 mg 100–250 mg 50 mg at bedtime Imipramine Dry mouth, drowsiness, nausea, anxiety/nervousness, orthostatic hypotension, myoclonus, hypertensive reactions 90 mg 30–90 mg 15 mg twice daily Phenelzine Nausea, diarrhea, anxiety/nervousness, sexual drysfunction, somnolence 60 mg 20–40 mg 20 mg Paroxetine Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 80 mg 20–60 rug Fluoxetine 200 mg 50–150 mg 50 mg Sertraline Somnolence, ataxia, memory problems, nausea, physical dependence, withdrawal reactions Benzodiazepines (various) Drowsiness, headache, orthostatic hypotension, bradycardia, exacerbation of asthma or obstructive pulmonary disease 240 mg/day 10–40 mg as needed 10 mg as needed Propranolol Ibtihal M.A. Ibrahim

34 Ibtihal M.A. Ibrahim

35 psychotherapy Ibtihal M.A. Ibrahim

36 Ibtihal M.A. Ibrahim CBT Exposure Applied relaxation
Social skills training Cognitive restructuring Cognitive Behavioral Group Therapy (CBGT) Ibtihal M.A. Ibrahim

37 performed both in and out of session
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 lower-ranked situations (e.g., moderately anxiety-provoking) and move up gradually performed both in and out of session Ibtihal M.A. Ibrahim

38 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

39 Social skills training:
Modeling Behavioral rehearsal Corrective feedback Positive reinforcement inevitably involves exposure to feared situations NB: people with social anxiety disorder may possess adequate social skills Ibtihal M.A. Ibrahim

40 Cognitive restructuring:
In cognitive restructuring, individuals are taught to: Identify negative thoughts Evaluate the accuracy of their thoughts Derive rational alternative thoughts Ibtihal M.A. Ibrahim

41 Cognitive-Behavioral Group Therapy:
12 weeks 6 patients rationale 1&2 sessions 2.5 hours instructions Ibtihal M.A. Ibrahim

42 Predictors of treatment response to CBT:
Expectancy for improvement. Homework compliance. Subtype of social anxiety disorder and avoidant personality disorder. Axis I comorbidity. Anger. Ibtihal M.A. Ibrahim

43 Thank You Ibtihal M.A. Ibrahim

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