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SOCIAL ANXIETY DISORDER (DSM-5 CRITERIA (Marked fear/anxiety about 1/+…
SOCIAL ANXIETY DISORDER
DSM-5 CRITERIA
Marked fear/anxiety about 1/+ social situations in which individual is exposed to possible scrutiny by others
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Fear/anxiety is out of proportion to actual threat posed by social situation & sociocultural context
Fear, anxiety or avoidance is persistent (6+ months)
Fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
EPIDEMIOLOGY
- Canadian lifetime prevalence: 8-13%
- Canadian 1-year prevalence: 6.7%
- Sex ratio: 2x more females
- Age of onset: childhood / early adolescence (13-20 years)
- Chronic course
- Highly comorbid 66.2% (mostly with GAD & MDD; SAD is strong risk factor for MDD in later adolescence)
ETIOLOGICAL FACTORS
BEHAVIOURAL INHIBITION
- early childhood temperament factor that involves fear of novelty
- related to shyness & social reticence in preschool & elementary school years
- assessed by introducing child to unfamiliar stimuli (developed by Kagan); inhibited babies are very upset by novelty, at higher risk for SAD later in life
- associated with greater than seven-fold risk for developing SAD
- one of the largest single risk factors for developing SAD
ENVIRONMENTAL MODERATORS
Parental anxiety - modelling, low opportunities for socialization, genetic diathesis
- shy parents have shy kids
- anxious parents can intensify child's anxiety
- can treat parents' anxiety so child's anxiety
- Parent Anxiety Training developed at Temple University
- school refusal is usually what brings parents to take child for treatment, but in turn parents are often treated
Insecure attachment - high parental rejection, low parental warmth
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BIOLOGICAL FACTORS
Brain areas
- amygdala (activation in response to threatening faces)
- insula
- fusiform cortex
- PFC
Neurotransmitters
- serotonin
- dopamine (deficits)
- oxytocin (impairments in oxytocin system)
PREDICTING ANXIETY - STUDY
- expected that high behavioural inhibition (BI) would relate to high anxiety later on, depending on inhibitory control (IC) & attention shifting (AS)
- Grass-Snow task - like Stroop task
- high BI related to high anxiety scores
- AS buffers effects of BI
- low IC ("bad") seems to also buffer BI (if you have very high IC, are excessively concerned about performance, monitoring performance out of fear that others are evaluating performance, so high IC might not actually be "good" thing)
ATTENTIONAL MECHANISMS IN SAD
- Increased vigilance to social threat cues
- Avoidance of socially relevant stimuli (eye gaze)
Examined gazing behaviour in patients with SAD versus healthy controls in response to angry, fearful, happy, & neutral faces using eye tracking
Hypotheses:
- early, reflexive attentional shifts towards eye region
- later avoidance of eye region
Results:
- those with SAD look significantly longer at eyes & focused on eyes whole time (clear hyper-vigilance for eye)
TREATMENT FOR SAD
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GROUP CBT
- as effective as individual CBT or pharmacotherapy
- more cost-effective
- incorporates exposure into therapy structure itself
MINDFULNESS
- often best over long term
BIOLOGICAL INTERVENTIONS
- SSRIs & SNRIs are first line (mild side effects, low risk of overdose, good for comorbidity)
- benzodiazepines (as-needed basis, abuse potential, can cause sedation)
- MAOIs (avoid foods with tyramine to prevent surge in blood pressure)
- D-cycloserine (DCS) - good with brief exposure therapy for public speaking
- atypical antipsychotics
- anticonvulsant gabapentin & pregabalin
- pharmacological treatment can be equivalent or superior to CBT (effects achieved more rapidly but CBT offers greater protection against relapse)