al Anxiety Disorder (S. BY DR. IBTIHAL MOHAMED ALY ASS. LECTURER PSYCHIATRY DEPARTMENT
Feb 24, 2016
Social Anxiety Disorder (S.A.D)BY
DR. IBTIHAL MOHAMED ALYASS. LECTURER PSYCHIATRY DEPARTMENT
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 skillsnegative
evaluationdifficulty of
being assertive
hypersensitivity to criticism
low self-esteem and feelings of inferiority
Ibtihal M.A. Ibrahim
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
The most frequent social trigger situations are
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:
Ibtihal M.A. Ibrahim
DSM-IV Diagnostic Criteria:
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
CLINICAL PICTUREIbtihal M.A. Ibrahim
Symptoms
Cognitive
Behavioral
Physiological
Ibtihal M.A. Ibrahim
Cognitive symptoms: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
Before
Ibtihal M.A. Ibrahim
Behavioral symptoms:Escape
avoidance behaviors
Controlled byMajor
avoidance behaviors
Minor avoidance behaviors Ibtihal M.A. Ibrahim
Physiological symptoms:
Blushing sweating
palpitations
shaking
nausea
Mind go blank
stomach ache
The walk disturbance
children with social
anxiety may display
tantrums, weeping,
clinging to parents
Ibtihal M.A. Ibrahim
ETIOLOGY
Ibtihal M.A. Ibrahim
Biological
•Genetic and family factors•Neural mechanisms.•Neuroanatomical.
Psychologic
al
•Cognitive context.•Evolutionary context.
Social
• Social experiences
• Social/cultural influences
Ibtihal M.A. Ibrahim
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:
Dopamine
Other neurotransmitters
Hormones and
neuropeptides
SerotoninNorepinephrine and Glutamate.
GABA
Oxytocin, Vasopressin,
CRF and Cortisol
Sociability is closely tied to dopamine neurotransmissionIbtihal M.A. Ibrahim
Neuroanatomical:
Amygdala
Anterior cingulate cortex
involved in the experience of
physical pain, also appears to be
involved in the experience of
'social pain'
• related to fear cognition and
emotional learning.
• hypersensitive amygdala.
Ibtihal M.A. Ibrahim
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
Evolutionary context:ev
olution
ary ex
planation
of anxiety
in-built 'fight or flight' system
vital
and
complex import
ance of social living
Specific dispositions to monitor and react to social threats
in mod
ern day society
tendencies can become more inappropriately activated and result in some of the cognitive 'distortions'
Ibtihal M.A. Ibrahim
Social experiences:
Person with increased
interpersonal sensitivity
Specific social phobia
Specific humiliating
social event
observing or hearing or verbal warning
longer-term effects of not fitting in
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
Co-morbidityIbtihal 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
Avoidant personality
disorder is in many ways
equivalent to pathologic
shyness
pervasive
pattern of
social inhibition and hypersensitivi
ty to negati
ve evalua
tion
Avoids occupational activities
Restrains from
intimate relationship
s
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
V
O
I
A
R
E
D
four or
more
Avoidant Personality
Disorder
Ibtihal M.A. Ibrahim
TREATMENTIbtihal M.A. Ibrahim
Psychotherapy
Combination
Pharmacotherapy
Ibtihal M.A. Ibrahim
PHARMACOTHERAPYIbtihal M.A. Ibrahim
MAOIs Benzodiazepines
SSRIs SNRIs
β- Blocker
Ibtihal M.A. Ibrahim
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 ParoxetineNausea, diarrhea, anxiety/nervousness, sexual dysfunction
80 mg 20–60 rug 20 mg Fluoxetine
Nausea, diarrhea, anxiety/nervousness, sexual dysfunction
200 mg 50–150 mg 50 mg SertralineSomnolence, 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
Ibtihal M.A. Ibrahim
psychotherapy
Ibtihal M.A. Ibrahim
CBT
Exposure
Applied relaxationSocial skills training
Cognitive restructuring
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 lower-ranked
situations (e.g., moderately
anxiety-provoking) 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:Modelin
gBehavioral rehearsal
Corrective feedback
Positive reinforceme
nt
inevitably involves
exposure to feared situations
NB: people with social
anxiety disorder may
possess adequate
social skills
Ibtihal M.A. Ibrahim
Cognitive restructuring:
Identify
negative
thoughts
Evaluate the
accuracy of their
thoughts
Derive rational alterna
tive though
ts
In cognitive restructuring, individuals are taught to:
Ibtihal M.A. Ibrahim
Cognitive-Behavioral Group Therapy:
6patients
2.5hours
12weeks
1&2sessions
rationale
instructions
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
Thank You
Ibtihal M.A. Ibrahim