1. Social Anxiety Disorder
Danielle Herring

2. DSM-5

3. DSM-5 Changes DSM-IV-TR DSM-5
Previously designated Social Phobia (Social Anxiety Disorder)
Now designated as Social Anxiety Disorder (Social Phobia)
Individuals over 18 must recognize their anxiety is excessive or unreasonable
Anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account (minimize overdiagnosis of transient fears)
6-month duration for individuals over 18
6-month duration for all ages
Generalized specifier (if fears include most social situations)
Generalized specifier deleted. Replaced with a “performance only” specifier.
The DSM-IV generalized specifier was problematic in that “fears include most social situations” was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking
or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response.

4. Social Anxiety Disorder (SAD)
Found under Anxiety Disorders
Other disorders also listed:
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Panic Disorder
Panic Attack Specifier
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder

5. Social Anxiety Disorder (SAD)
Essential feature:
Social anxiety disorder is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others.
In children the fear or anxiety must occur in peer settings and not just during interactions with adults.

6. Diagnostic Criteria
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.
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).
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.
The social situations are avoided or endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

7. Diagnostic Criteria
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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.
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.
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.

8. Diagnostic Specifier Performance Only:
Performance fears that typically impair one’s professional life
Can manifest in work, school, or academic settings
Those with performance only SAD do not fear or avoid nonperformance social situations.

9. Associated Features
Inadequately assertive or excessively submissive behavior
Rigid body posture
Inadequate eye contact
Overly soft voice tone
Blushing – hallmark physical response to SAD

10. Prevalence of SAD
12-month prevalence estimate for the United States is approximately 7%
12-month prevalence rates in children and adolescents are comparable to those in adults
Lower 12-month prevalence estimates are seen in much of the world using the same diagnostic instrument, clustering around 0.5%–2.0%
Prevalence rates decrease with age
12-month prevalence for older adults ranges from 2% to 5%
Generally, higher rates found in females than males in the general population - odds ratios ranging from 1.5 to 2.2:1
Gender difference in prevalence is more pronounced in adolescents and young adults
Median prevalence in Europe is 2.3%
Prevalence in the United States is higher in American Indians and lower in persons of Asian, Latino, African American, and Afro-Caribbean descent compared with non-Hispanic whites

11. Development & Course of SAD
Median age at onset of social anxiety disorder in the United States is 13 years.
75% of individuals have an age at onset between 8 and 15 years
Onset can also occur in early childhood.
First onset in adulthood is relatively rare.
Onset of social anxiety disorder may follow a stressful or humiliating experience or may develop slowly .
In the community ~30% of individuals experience remission of symptoms within 1 year, and ~50% experience remission within a few years.
Without a specific treatment, for ~60% of individuals course will take several years or longer.

12. Risk Factors of SAD Environmental:
Childhood maltreatment & adversity (not causal)
Temperamental:
Underlying traits that predispose for SAD include behavioral inhibition & fear of negative evaluation
Genetic/Physiological:
Traits predisposing individuals, such as behavioral inhibition, are strongly genetically influenced
Genetic influence is subject to gene-environment interaction
SAD is heritable (performance-only anxiety less so)
First-degree relatives have a two to six times greater chance of having SAD
The DSM didn’t provide actual estimates for these risk factors

13. Comorbidity
Often comorbid with bipolar disorder, body dysmorphic disorder, other anxiety disorders, major depressive disorder, and substance use disorders
Onset of SAD generally precedes the other disorders, except for specific phobia and separation anxiety disorder
SAD (but not SAD, performance only) is often comorbid with avoidant personality disorder
In children, comorbidities with high-functioning autism and selective mutism are common
Females - higher comorbidity with depressive, bipolar, and anxiety disorders
Males - more likely to have ODD or CD and use alcohol or illicit drugs to relieve symptoms of SAD
The DSM did not provide estimated ‘rates’ of these comorbidities however I do have a slide in the lit review that gives comorbidity rates per the National Comorbidity Survey

14. DSM-5 Model of SAD Temperamental Factors: Behavioral inhibition
Fear of negative evaluation
Genetic/
Physiological Factors
Core Features:
Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others
Environmental Factors:
Childhood maltreatment & adversity
Associated Features:
Inadequately assertive or excessively submissive
Rigid body posture
Inadequate eye contact
Overly soft voice tone
Blushing
Performance Only Specifier:
If the fear is restricted to speaking or performing in public.

15. Literature Review

16. Onset & Prevalence
Generally in late childhood/early adolescence. Not usually diagnosed before age 10 (Weis, 2008).
Mean age of onset 15.1 years (Fink et al., 2009).
Average age of onset is considered mid-adolescence (Schneier et al., 1992).
Lifetime prevalence of 12% and 12 month prevalence of 7.1% (Kessler et al., 2005).
Lifetime prevalence between 5% and 15% (Heimberg et al., 2000).

17. Typical Course Most children do not have SAD long term (Weis, 2008).
Cited:
Pine, Cohen, Gurley, Brook & Ma (1998), most adolescents did not continue to meet diagnostic criteria in adulthood.
An epidemiologically selected sample of 776, 9–18 year olds, were evaluated with structural interviews in 1983, 1985, and 1992.
Last, Perrin, Hersen, & Kazdin (1996)
In a study of 84 children, about half did not show the disorder 3 years after the initial diagnosis.
Does not specify if this means full remission, rather simply not enough to meet DX criteria

18. Commonly Feared Situations
Most common feared situations: formal presentations & unstructured social interactions.
Intense anxiety reported for:
Reading aloud in class
Giving a class presentation
Performing for others on stage
Performing at an athletic event
(Weis, 2008).
Giving a speech, participating in a
meeting, talking to people they do
not know (Fink et al., 2009).
Also in initiating conversations with strangers, asking questions, or attending parties.
Situations where they feel they might be judged negatively by others. Tests – criticism from teachers. Eating in public – others watching and criticizing their diet/etiquette. Social avoidance negatively reinforced by anxiety reduction.

19. Commonly Feared Situations
This study compares and contrasts the clinical presentation of SAD among children (ages 7-12) and adolescents (ages 13-17). 150 children (n = 74) and adolescents (n = 76) with a primary diagnosis of SAD participated in the study. 
Highest – oral reports/reading aloud, initiating/joining conversations, speaking to new/unfamiliar people, speaking to adults, and musical or athletic performance

20. Associated Risk Outcomes
Academic underachievement
Underperformance at work
Inability to work
Higher rates of alcohol and drug abuse
Higher unemployment rates in patients with SAD
Fink et al., 2009

21. Comorbidity
Depression, social isolation, substance use problems (Weis, 2008).
Bipolar disorder (22% BD patients had experienced SAD)
Eating disorders
Other anxiety disorders
Selective mutism
ODD CD
Rates on following slide…

22. aOR = odds ratio adjusted for adolescent sex, age, and other emotional and behavioral disorders (except the disorder of interest); CI = confidence interval
In particular, adolescents with generalized social phobia displayed high rates of specific phobia (13%), agoraphobia (27.0%), panic disorder (20.5%), SAD (18.1%), ODD (12.5%),
and drug use disorders (13.0%).
GAD - generalized anxiety disorder; ODD - oppositional defiant disorder; PTSD - posttraumatic stress disorder; SAD - separation anxiety disorder
The National Comorbidity Survey Replication–Adolescent Supplement is a nationally representative face-to-face survey of 10,123 adolescents 13 to 18 years of age in the continental United States.

23. Genetic Factors
Family studies – tendency to experience anxiety runs in families .
Twin studies – 50% of variance in symptoms attributable to genetics (Weis, 2008).
First-degree relatives of adults with SAD are 3x as likely to be affected with SAD (Ollendick & Hirshfeld-Becker, 2002).
Family studies have consistently found significantly higher rates of SAD in the relatives of socially phobic probands (Fyer, Mannuzza, Chapman, martin, & Klein, 1995; Hughes, Furr, Sood, Barmish, & Kendall, 2009; Reich & Yates, 1988).
Proband - a person serving as the starting point for the genetic study of a family
monozygotic (MZ; identical), dizygotic (DZ; fraternal) twins who share no more genetic material than siblings (roughly 50%)

24. Genetic Factors cont.
Twin studies have consistently found evidence for the heritability of general traits:
Behavioral inhibition (33%)
Shyness (22%)
Fear of negative evaluation
(Daniels & Plomin, 1985; Eley et al., 2003; Stein, Goldin, Sareen, Zorrilla, & Brown, 2002; Warren, Schmitz, & Emde, 1999)
Beatty, Heisel, Hall, Levine, & La France conducted a meta-analysis of twin studies. Heritability estimate of .65 for SAD (2002).
Controversy surrounding twin studies:
Kendler, Neale, Kessler, Heath, and Eaves (1992) found a higher concordance rate for SAD among MZ (24%) than DZ (15%) female twins
Skre, Onstad, Torgersen, Lygren, & Kringlen found similar concordance rates for SAD among MZ and DZ twins, suggesting that there is not a specific genetic contribution (1993).

25. Environmental Factors
Parent-child interactions:
Parents of children with social phobia:
Generally more controlling & overprotective
High levels of critical behavior toward children
Avoid emotional-charged discussions
Likely to have social anxiety – anxiety responses can be taught, modeled, or reinforced.
Dadds, Barrett, Rapee, & Ryan (1996) - Ambiguous situations interpreted as hostile/dangerous by children. Parents supposed children’s decisions to overreact and withdraw from social situations.
Interactions bidirectional – children’s behavior can also cause parents to be controlling, protective, or critical (Weis, 2008)

26. Environmental Factors cont.
Lieb et al. (2000) – parental rejection and overprotection more frequent when parents had psychopathology
Parents of individuals with social anxiety are inclined to be more socially isolated (Caster et al., 1999).
Less likely to facilitate play dates, supervise peer interactions, or monitor activities (Masia & Morris, 1998).

27. Temperamental Factors
Behavioral inhibition (BI) marks an increased risk for anxiety disorders in general and SAD specifically (Higa- McMillan & Ebesutani, 2011).
Manifests differently at different stages:
Inhibited toddlers: React to new things/situations with fear, clinging, and avoidance
Inhibited elementary school children: Quiet isolation with unfamiliar peer groups, shyness with unfamiliar adults
Kagan et al. (1994) – followed 2 independent cohorts of inhibited toddlers -> BI moderately preserved through early adolescence.
Biederman et al. (2001) found that SAD more common among children with BI than without BI.
Behavioral inhibition is defined as withdrawal, wariness, avoidance, shyness, social uneasiness, and fear of unfamiliar situations, people, objects, and events
Kagan – through lab and peer-play observations

28. Temperamental Factors
Hayward et al. (1998) found that adolescents with childhood BI were at 4 to 5 times greater risk of developing SAD than those who did not exhibit BI (sample of 2000 ninth graders with retrospective self-report measures).
Hirshfeld-Becker et al. (2007): 5-year follow-up study and found that BI specifically predicted the onset of SAD and was not associated with any other anxiety disorders.
Biederman et al. (1993):
216 inhibited and non-inhibited children from a sample of parents with panic disorder and/or MDD and non-anxious and non-depressed controls.
Inhibited subjects had higher rates of either SAD and avoidant disorder (DSM-III-TR)
Does not specify number split

29. Neurobiological Factors
Dopaminergic dysregulation
Tiihonen et al., (1997), reported that striatal dopamine reuptake site densities were lower among SAD patients than a comparison group matched on age and gender. (11 patients with SAD and 11 healthy controls).
SAD patients with low dopaminergic activity also found by Schneier et al., (2000).
Atypical serotonergic functioning
Respond well to drugs inhibiting serotonin reuptake (SSRIs) (Bouwer & Stein, 1998; Katzelnick et al.,1995)
Tancer et al. (1994–1995): Greater cortisol responses to fenfluramine than a comparison group without anxiety—reflecting differential levels of stimulation of central serotonin 5-HT2C receptors.
Lanzenberger et al., (20070: PET study also identified reduced binding of a specific serotonin receptor (5-HT1A) related to SAD.
Tiihonen et al., (1997), examined the density of dopamine reuptake sites via single photon emission computed tomography. They reported that striatal dopamine reuptake site densities were lower among SAD patients than a comparison group matched on age and gender.
Low dopaminergic functioning also found in other populations (substance abuse)

30. Neurobiological Factors cont.
2004 – Gelernter et al. conducted first genome wide linkage study in SAD patients.
Suggested linkage of chromosome 16 markers near norepinephrine transporter protein
Smollen et al – strong association of corticotropin releasing hormone (CRH) gene and BI (2005).
Etkin & Wager, 2007 – fMRI studies that show hyperactive areas during emotional processing of SAD patients:
Parahippocampal and fusiform gyrus
Interior frontal gyrus
Amygdala*
Insula*
* - most consistently found to be hyperactive

31. Neurobiological Factors cont.
2007 – Lanzenberger et al., PET study of serotonergic contribution to pathophysiology of SAD.
Compared5-HT1A receptor in male SAD (12) and control patients (18)
SAD patients appear to have lower receptor binding in mesiofrontal areas, the amygdala and insula, which are assumed to be part of the neural circuitry of SAD.
Figure 1. Serotonin-1A receptor distribution in the human brain. The distribution was measured with PET using the radioligand (carbonyl-11C) WAY and superimposed on magnetic resonance images. The picture shows coronal, sagittal and axial views of a male social anxiety patient (A) and a healthy male control subject (B). The color bar indicates serotonin-1A receptor binding potential values. The serotonin-1A receptor binding is reduced across all brain regions in the patient
The fact that symptom improvement, most commonly achieved with selective serotonin reuptake inhibitors, is reversible by serotonin depletion also points out the key role of this transmitter in SAD.

32. Conditioning Factors
Direct exposure to socially traumatic events is believed to mark the onset or dramatic increase of symptoms (Higa- McMillan & Ebesutani, 2011).
Many individuals with SAD can recall a past traumatic event associated with the onset of their disorder (Beidel & Turner, 2007).
Öst and Hugdahl - 58% of their SAD sample reported that their SAD-related fears were the result of direct, traumatic social experiences (1981).
Higa-McMillan—how many kids with SAD have a positive history of socially traumatic events vs how many kids who have experienced socially traumatic events develop SAD

33. Conditioning Factors
Stemberger, Turner, Beidel, & Calhoun - 56% of individuals with specific SAD and 40% of individuals with generalized SAD recalled a traumatic event that precipitated the onset and/or increase in their symptoms (1995).
92% of adult sample diagnosed with SAD (n=26) reported a history of severe teasing in childhood (McCabe, Antony, Summerfeldt, Liss, & Swinson, 2003).

34. Developmental Model of the etiology of SAD in adolescents
There are multiple types of predisposing factors, such as neurobiological vulnerabilities, inhibited temperament, poor attachment, and negative parenting styles. These vulnerabilities interact to set the stage for the development of SAD
Higa-McMillan & Ebesutani, 2011.

35. My Model of SAD Comorbidity: Depression
Social isolation
Substance use problems
Bipolar Disorder
Other anxiety disorders
Conditioning Factors/ Parenting Style
Cultural Factors
Core Feature:
Marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others
Environmental Factors
Temperamental/ Genetic Factors
Neurobiological Factors
Performance Only
Secondary Features:
Inadequately assertive or excessively submissive
Rigid body posture
Inadequate eye contact and Overly soft voice tone
Blushing
Academic underachievement
Underperformance at work
Inability to work
Alcohol and/or drug use
Increased possibility of unemployment

36. References
Beatty, M., Heisel, A., Hall, A., Levine, T., & La France, B. (2002). What can we learn from the study of twins about genetic and environmental influences on interpersonal affiliation, aggressiveness, and social anxiety?: A meta-analytic study. Communication Monographs, 69, 1–18. doi: / Beidel, D. C., & Turner, S. M. (2007). Shy children, phobic adults: The nature and treatment of social anxiety disorder (2nd ed.). Washington, DC: American Psychological Association. doi: / Biederman, J., Hirshfeld-Becker, D. R., Rosenbaum, J. F., Hérot, C., Friedman, D., Snidman, N., Faraone, S. V. (2001). Further evidence of association between behavioral inhibition and social anxiety in children. The American Journal of Psychiatry, 158, 1673–1679. doi: /appi.ajp Bouwer, C., & Stein, D. J. (1998). Use of the selective serotonin reuptake inhibitor citalopram in the treatment of generalized social phobia. Journal of Affective Disorders, 49, 79–82. doi: /S (97) Burstein, M., He, J., Kattan, G., Albano, A., Avenevoli, S., & Merikangas, K. R. (2011). Social phobia and subtypes in the National Comorbidity Survey–Adolescent Supplement: Prevalence, correlates, and comorbidity. Journal Of The American Academy Of Child & Adolescent Psychiatry, 50(9), doi: /j.jaac

37. References
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38. References
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39. References
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40. References
Tiihonen, J., Kuikka, J., Bergström, K., Lepola, U., Koponen, H., & Leinonen, E. (1997). Dopamine reuptake site densities in patients with social phobia. The American Journal of Psychiatry, 154, 239–242. Warren, S. L., Schmitz, S., & Emde, R. N. (1999). Behavioral genetic analyses of self-reported anxiety at 7 years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1403–1408. doi: / Weis, Robert. (2008). Abnormal Child and Adolescent Psychology. California: Sage Publications.