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Symptomatology, Prevalence, and Impact of Social Anxiety Disorder

Introduction
This essay will review Social anxiety disorder (SAD: American Psychiatric Association (APA), 2013), a psychiatric diagnosis manifested by persistent fear of negative evaluation in social situations leading to significant impediment in people’s wellbeing and mental health development. Symptomatology, prevalence, and impact of SAD will be evaluated along with a recommended assessment process. It will also explore the role played by culture in the presentation of SAD and the importance of this literature for the assessment and treatment of SAD. Lastly, a review of the literature to determine the effectiveness of dominant treatment options of SAD will be discussed.
Diagnosis and presentation
Table 1 summarizes the diagnostic criteria for SAD in DSM-5. As shown in Table 1, the essential feature of SAD is a marked, or intense, fear or anxiety of one or more social situations in which the individual may be scrutinized by others (criteria a). Social situations vary from social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking in public), and performing in front of others (e.g., giving a speech). According to research (Stein, Torgrud, & Walker, 2000) majority of patients with SAD experience fear in more than one situation; however the type of feared situation can vary across individuals and groups (Fan & Chang, 2015)For instance, in a cross-national comparison study (Marques, Robinaugh, LeBlanc, & Hinton, 2011)found that Australians reported higher dating fears and fears of initiating conversation while the Swedish sample reported higher observational fears such as fears of eating, drinking, and writing in public. Furthermore, recent epidemiological studies have indicated that some individuals diagnosed with SAD manifest fear and anxiety that is restricted performing in public (Knappe et al., 2011; Piqueras, Olivares, & Lopez-Pina, 2008). Individuals with performance only SAD do not fear or avoid non-performance social situations, and present fears that are circumscribed to their professional lives (e.g., giving a speech, athletic performance, or a class presentation) (Solomon, Leichsenring, & Leweke, 2017). Accordingly, DSM- 5 includes a new subgroup, Performance fears, to acknowledge the distinctive features associated with performance anxiety. Performance only SAD is more likely to be present in males in western populations (Peyre et al., 2016). In contrast, East-Asian populations that meet the criteria for SAD present increased fear in social interaction (Fan & Chang, 2015).
While fear associated with exposure to some of the above situations is common in the general population, individuals with SAD worry excessively that he or she will be negatively evaluated – for example, being judged as anxious, weak, stupid, boring, or unlikable (criteria b, Table 1).  In earlier publications of the DSM, the primary fear in SAD was that the person would behave in a way that would be humiliating or embarrassing. In the recent DSM-5 criterion, however, broader interpretations and manifestations of SAD are acknowledged with a comprehensive focus on negative evaluation linked with SAD rather than the previous narrower focus on humiliation and embarrassment. Clearly, empirical research indicate that humiliation and embarrassment to be significant concerns for a majority of individuals with SAD (Heimberg et al., 2014) however, fear of rejection and fear of offending others have been the central concern in individuals from Asian cultures.(…..). For instance, individuals suffering from Taijin Kyofusho (TKS), a culture-specific expression of SAD, become increasingly distressed regarding how they may offend others as opposed to embarrassing themselves, for example by a gaze or by showing anxiety symptoms such as blushing, sweating, or trembling (Choy, Schneier, Heimberg, Oh, & Liebowitz, 2008; Heinrichs et al., 2006).
Exposure to social situations almost always provoke anxiety symptoms in individuals diagnosed with SAD (Criterion C, Table 1). However, the degree and type of expressed anxiety may vary with regard to age and gender. For example, children may express their anxiety somewhat differently from adults. They are more likely to cry, freeze, or display behavioural outbursts such as tantrums when confronted with the feared situation (Heimberg et al., 2014; Hitchcock, Chavira, & Stein, 2009). In contrast, older children and adolescents report higher panic-like symptoms with exposure to social situations and anticipatory anxiety (i.e. excessive preparation) that may occur days or weeks in advance of upcoming social situations (Rao et al., 2007). Older adults express social anxiety at lower levels across a broader range of situations (Gretarsdottir, Woodruff-Borden, Meeks, & Depp, 2004). In terms of gender, women are more likely to display heightened physiological symptoms (i.e., trembling, blushing, higher heart rate) associated with SAD relative to men (Asher, Asnaani, & Aderka, 2017). Besides, this anxiety is out of proportion to the actual threat posed by the situation (Criteria E, Table 1). In addition, studies have indicated that socially anxious individuals often underestimate the level of their social performance and overestimate the fear and likelihood of negative outcomes attributed to situations (Foa, Franklin, Perry, & Herbert, 1996; Spokas, Rodebaugh, & Heimberg, 2007).
As means of reducing anxiety and fear individuals with SAD are highly motivated and repeatedly perform avoidance or escape behaviours from social situations (Criteria d). They may engage in direct avoidance (rejecting social offerings, refusing school etc.) or subtle avoidance (distracting attention to others, avoiding eye contact) (Panayiotou, Karekla, & Mete, 2014; Salters-Pedneault, Tull, & Roemer, 2004). When avoidance is not feasible individuals may tolerate social situations with feelings of intense distress (Helbig‐Lang & Petermann, 2010). While broader patterns of social avoidance and escape are commonly found among adolescents and adults, children often display disinterest in age-appropriate social and academic activities(Rao et al., 2007). The duration of SAD is typically 6 months (Criterion F), which helps discriminate a diagnosis from common social fears and normative shyness (APA, 2013)
Table 1
DSM-5 Diagnostic criteria for social anxiety disorder (Social Phobia)

       Criteria
  1. 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).
  1. 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
  1. The social situations almost always provoke fear or anxiety.
  1. The social situations are avoided or endured with intense fear or anxiety.
  1. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
  1. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
  1. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  1. 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.
  1. 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.
  1. 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.

Note. Adapted from DSM-5 = Diagnostic and Statistical manual of Mental disorders, 5th edition (p. 202-203) by American Psychiatric association, 2013. Copyright 2013 by the American psychiatric Association.
Impact
Humans as social beings require social interaction and relationships in daily life for effective functioning and increased quality of life (Maricic & Stambuk, 2015). The consequences of increased social avoidance and anxiety, therefore, is correlated with impairments spanning relationship, family, employment, educational domains  other important areas of functioning(Pilling et al., 2013). In children and adolescents increased SAD may result in fewer friends and stronger feelings of social isolation(Rao et al., 2007) They may also develop poor social skills (i.e. assertiveness, body language, communication skills (Hitchcock et al., 2009; Piqueras et al., 2008). Educational achievement can be impaired, with higher risk of school drop outs and obtaining poorer qualifications (Van Ameringen, Mancini, & Farvolden, 2003). One study found that average wages of people with SAD were 10% less than that of the non-clinical population (Katzelnick et al., 2001) Although majority of people with SAD are employed, they report lower workplace productivity, spending more days off work, and seeking employment in jobs that require fewer social contact (Crome et al., 2014). Furthermore, individuals with SAD are more likely to be single, unmarried, or divorced and have no children (Fehm, Pelissolo, Furmark, & Wittchen, 2005; Wittchen, Fuetsch, Sonntag, Muller, & Liebowitz, 1999). In older adults, caregiving duties and volunteer activities can be undermined (Gretarsdottir et al., 2004). In addition, people with SAD have a higher risk of developing other anxiety disorders, unipolar depression, and substance use disorder (Fehm, Beesdo, Jacobi, & Fiedler, 2008).
Knowledge of age specific and cross-cultural differences in clinical presentation and impact of SAD is important for developing and implementing more targeted assessment and treatment strategies (Rao et al., 2007).
Prevalence
SAD is one of the most common psychiatric disorders in Australia. The most recent snapshot of SAD in Australia derives from the 2007 National Survey of Mental Health and Wellbeing. The survey data revealed high as 8.4% of Australian adults develop SAD at some point in their lives with 4.2% experiencing SAD symptoms in the past 12 months, compared to lifetime(12 month) prevalence rates of other anxiety disorders : 6.1%(1.9%) for generalised anxiety disorder,3.5% (1.8%) for panic disorder, and 2.3% (1.2%)for agoraphobia(McEvoy, Grove, & Slade, 2011). Higher 12-month prevalence rates have been found in other countries:  7.1% in USA (Ruscio et al., 2008) , 6.4% in Chile (Vicente et al., 2006), and 5.1% in New Zealand (Wells et al., 2006). Moreover, data from the National Comorbidity Survey indicates that SAD is the third most common psychiatric condition after major depression and Substance use disorder (Kessler et al., 2005).Nevertheless, the 12-month prevalence rate of SAD in Asian regions, has been reported to be much lower: 0.6% in Korea(Cho et al., 2007), 0.2% in China(Shen et al., 2006) and 0.8% in Japan(Kawakami et al., 2005). 12 month prevalence rates of children and adolescents are found to be similar to those of adults (McEvoy et al., 2011). However, SAD prevalence in the elderly has been reported to be much lower (Wolitzky‐taylor, Castriotta, Lenze, Stanley, & Craske, 2010). The prevalence of SAD was higher for women than men (1.5: 2.2) at all age groups and the largest difference was found in adolescents and young adults(Grant et al., 2005).
Assessment
A comprehensive clinical assessment of SAD, as with any diagnosis, relies on a multimethod assessment approach that emphasises mindful inquiry into the presenting problem by describing a client’s impairment, and informing and guiding the intervention process (Letamendi, Chavira, & Stein, 2009). A funnel approach is suggested to be employed in the assessment of SAD, in which the process begins with a broad-based evaluation followed by a more targeted evaluation of the presenting problem. This involves the use of mental status exam(MSE), diagnostic interviews, and specific psychological tests (Pilling et al., 2013).
Several issues should be addresses in the assessment of SAD. First, as people with SAD almost always experience considerable anxiety during social interactions, although motivated to seek psychotherapy, discussing their anxiety and fears with a stranger can be distressing. Therefore, an important initial task of the clinician is to create an environment in which individuals feel comfortable and secure discussing their issues (Solomon et al., 2017). Furthermore, individuals with SAD tend to overestimate the fear, anxiety, and the likelihood of negative outcomes in social situations (Foa et al., 1996; Spokas et al., 2007). Therefore, as stated in DSM-5, a primary role of the clinician is to determine whether the anxiety is, indeed, disproportionate to the actual risk (APA, 2013). However, when making the judgement, the individual’s sociocultural background needs to be considered (Solomon et al., 2017).
Clinical Interview
A proposed starting point for a referral concern of SAD would be the Clinical Interview, considered the gold standard of the assessments(Nordgaard, Revsbech, Saebye, & Parnas, 2012). In addition, some clinicians have suggested the use of more global self-report measures (e.g. Depression anxiety and stress scale, DASS 21) prior to conducting the initial interview as an attempt to collect information of the client’s current condition and establish a productive dialogue (Stravynski & Greenberg, 1998). The MSE at the beginning of a clinical interview provides important information about a client’s level of psychological functioning at a given time.  Empirical research has highlighted the importance of the MSE for initial recognition of possible psychomotor agitation and disruptive speech and thought processes in individuals with SAD (Daniel & Gurczynski, 2010).
An open ended clinical interview at the beginning would not only assist in obtaining general information but may also communicate empathy and develop a strong therapeutic alliance which are factors found to have an impact on the success of psychotherapy (Horvath, Del Re, Fluckiger, & Symonds, 2011). Developing a strong therapeutic alliance with individuals who have interpersonal relationship difficulties, such as those clients with SAD is particularly important as the anxiety typically associated with social situations in SAD may include the therapy setting itself; hence, it is important for clients to form strong working alliances with their therapists to actively engage in the therapeutic procedure (Hayes, Hope, VanDyke, & Heimberg, 2007). During assessment with children and adolescents, the therapeutic alliance should be formed not only with the child but also with the primary caregiver. Therefore, for its’ rigid format, relying on a structured interview can depreciate rapport with the client and the opportunity to develop a strong alliance (Nordgaard et al., 2012). On the other hand, as SAD is associated with a high prevalence of co-occurring conditions (I.e. depression and substance abuse) a clear differential diagnosis and knowledge of other issues is critical for patient diagnosis and treatment planning. Thus, for an effective diagnostic evaluation, conducting a general semi-structured interview in addition to an open-ended interview is recommended.
Semi-structured Interview. Well conducted semi-structured interviews is useful as they direct the clinician through the diagnostic decision-making process while utilising clinician’s judgment. Clinician version of the Structured Clinical Interview for DSM-5 (SCID-5) and Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) are the latest versions of the most commonly used semi-structured interviews for diagnosis of SAD. SCID -5 offers a flexible administration of the interview as it allows the clinician to skip-out of items when the client does not present concerns consistent with a specific diagnosis (First, 2015). ADIS-5 has been endorsed for its inclusion of situational parameters in the diagnosis of SAD and the ‘child friendly’ structure that facilitates the assessment of SAD in children and adolescents the interview schedule(Brown & Barlow, 2014). An advantage of both instruments is the inclusion of sections for obtaining additional information such as family history, medical and psychiatry history, and socio-occupational information(Letamendi et al., 2009). Reliability studies have demonstrated fair estimates for both SCID-5 (kappa =.59) and ADIS-5 (kappa = .64) for the diagnosis of social phobia (Letamendi et al., 2009)Nevertheless, limitations of the two instruments include the length of time and training required for administration (Brown & Barlow, 2014; First, 2015).
Clinician-rating scales
To further clarify diagnosis and narrow down test hypotheses, specific psychological measures should be administered to finalise the initial assessment. One form of specific measures include clinician rating scales which are primarily designed to rate various dimensions of social anxiety disorder (Beidel & Turner, 2007). The two most commonly used clinician-rated instruments are Liebowitz Social Anxiety Scale (LSAS) and Brief Social Phobia Scale (BSPS).
 
(finally say this) Together these approaches represent a thorough assessment of SAD by assisting in the initial diagnosis, identifying associated conditions and parameters of the disorder, and monitoring treatment progress and outcome.
Treatment
Studies have generally found that SAD is a naturally unremitting condition in the absence of treatment. https://www.ncbi.nlm.nih.gov/books/NBK327674/
Psychoeducation
(e.g., about the nature of social anxiety, description of treatment
strategies) is typically the focus of the first treatment session, and continues through-
out the course of therapy, particularly as new strategies are introduced. At the first
session, basic information should be provided regarding the number of sessions, length
and frequency of sessions, and the expectation that clients will complete homework
between sessions. Psychoeducation also includes information about a core construct
of social anxiety (i.e., fear of negative evaluation) and the high frequency of shyness
and SAD in the general population (to normalize the experience of social anxiety and
to let clients know that they are not alone)
Leading treatments for SAD
 
 
CBT
 
Group therapy
 
 
Pharmacotherapy
 
Other treatments.
 
Social skills training( highlight therapist role)
 
Contemporary treatment protocols for SAD include cognitive therapy (CT), behavior therapy, social skills training, and more recently, interpersonal psychotherapy. Of those interventions, CT and behavioral therapy—usually subsumed under the general term cognitive behavioral therapy (CBT)—are the most validated approaches
Conclusion
This review highlighted the range of instruments available to assist the diagnosis and assessment of SAD. MSE, the clinical interview (i.e. semi-structured interview), and the use of self-report and clinician rating scales were recommended for a comprehensive clinical evaluation. Despite being associated with a high degree of distress, disability, and functional limitation, social anxiety disorder (SAD) often goes undetected and untreated.
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