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Problem 1 Anxiety and Hyperventilation 14/4/2020
Learning goals
1. What is an anxiety disorder?
2. What types of anxiety disorders are there? (Social Anxiety Disorder (Social Phobia),Panic
Disorder, Generalized)
SAD
Hofmann → Social Anxiety Disorder (in The Wiley Handbook of Anxiety Disorders)
Diagnostic features
- Social anxiety was defined as ‘clinically significant anxiety provoked by exposure to
certain types of social or perform situations, often leading to avoidance behavior’ in
the DSM-IV-TR. It includes the cognitive and affective components that are activated
by the perception of possible criticism by others. Individuals with SAD are excessively
concerned about how they are perceived and evaluated by others, including
significant others and strangers.
- Social anxious individuals fear and avoid a variety of situations including social
performance and interactions.
o The most commonly feared situation is public speaking, which requires being
in front of other people and putting on a performance, as do eating, drinking,
acting, or playing an instrument. → These kinds of fears can be classified as
performance fears.
o Face-to-face conversations in settings like meetings, social gatherings, and
parties or novel/ambiguous situations can be classified as interactional fears.
▪ Examples: Initiating social conversations, meeting strangers, dating, or
interaction with authority figures.
o Some individuals may only have a fear of certain performance situations, while
others may depict a wide range of fears that include various performance
situations and interactional fears.
- Social anxiety:
o Cognitive aspects: negative thoughts and high standards about one’s own
performance, and unrealistic beliefs about other people’s standards.
o Behavioral aspects: escape and avoidance. Individuals with social anxiety
typically avoid possible anxiety-evoking situations that prevent potential
aversive exposure. In those circumstances, the individual never has the chance
to observe or learn more appropriate or nondistressing ways to cope with the
situation.
o Somatic symptoms: sweating, tremors (trillen), and hot flushes or subtle
behavioral signs of anxiety.
History of diagnosis
- Fear and anxiety about social situations might have existed since the emergence of
social relations. First description was made by Hippocrates (1870).
- The definition of SAD as we know it today dates back only to 1966. Marks and Gelder
mentioned a condition in which the individual feels very anxious when he or she is
subjected to critical observation or examination by others while performing a specific
, task. In their description of ‘social anxiety’, individuals with the disorder were defined
as having ‘phobias of social situations…’.
- SAD was first introduced as diagnostic category with DSM-III (1980) and was known as
‘social phobia’. Definition included ‘significant distress’ as a result of having fear of
performance situations. Diagnostic criteria did not cover fact that most individuals
with SAD fear more than one social situation when they stated ‘generally an individual
has only one social phobia’.
- Diagnosis underwent some changes in DSM-III-R: more extensive criteria with greater
specificity.
Diagnostic subtypes
SAD is a heterogeneous diagnostic category.
- Since the DSM-II and up until the DSM-IV-R, clinicians needed to specify a generalized
subtype of SAD if the social phobic individual fears ‘most social situations. However,
the DSM did not indicate the number or type of social situations that should be
included in the generalized subtype of SAD.
- In the DSM-V, this has been replaced by performance-only subtype that should be
coded if the fear is restricted to speaking or performing in public.
- In DSM-V, SAD and Avoidant Personality Disorder (APD) are diagnosed as separate
entities and a person could meet the diagnostic criteria for both disorders (DSM-II
ruled diagnosis of SAD out if person met criteria for APD). They have at least four
overlapping criteria.
Thus, 2 diagnostic subtypes:
Generalized SAD (with and without APD) Non-generalized SAD – “performance-only”
- At least 50% of individuals with SAD meet the criteria - Later onset (17)
- Earlier onset (11)* - Higher heart rate respons
- Higher Subjective Anxiety - Experiences more of a fear response (greater
physiological response to a specific stimulus situation)
- Lower heart rate respons
- Show lower vigilance to general threatening social cues
- Show greater tendency to have an anxiety response when
confronted with social threats (excessive public self-awarenss)
- Show greater vigilance (waakzaamheid, behoedzaam) to
general threatening social cues
- Greater impairment in all life domains
*An early onset of SAD has a greater negative impact on children in terms of opportunities for social
success and this may be one driving factor in the generalization of social fears and avoidance patterns.
,Cognitive models of SAD suggest that during social situations various psychological processes
characterize the disorder, including fear of negative evaluation, exaggerated self-focus, and
maladaptive cognitions rewarding self and others. There is an important cognitive component
associated with SAD and subtypes of SAD differ in cognitive processing (see table).
SAD also appears to be linked to certain forms of social concerns that seem to be culturally specific.
Cultural considerations in social anxiety seem to have implications for the differential diagnosis.
- Example of cultural differences on social concerns: emotional disorder with similar
features to SAD called taijin kyofusho (TKS), which appears to be particularly prevalent
in the Japanese and Korean culture. It means the disorder of fear of interpersonal
relations. Similar to individuals with SAD, patients with TKS are concerned about being
observed and avoid a variety of social situations. However, TKS is characterized by
cognitions related to the fear of embarrassing others with one’s presence instead of
the fear of embarrassing oneself. In Japan, emotional control and inhibition of
emotional expression are promoted in order not to violate social rituals and protocols.
The distinctions of such cultural differences are important for an accurate diagnosis.
Comorbidity
Major issue → determine whether SAD and APD represent 2 distinct clinical categories or not.
1. Studies consistently report a high rate of comorbidity between the generalized
subtype of SAD and APD.
- Both disorders are highly related in terms of symptoms and they mainly differ in the
severity of the disorder, as APD appears to have more disability, more personality
problems, and a lower level of conscientiousness. Moreover, 42% comorbidity rate for
SAD in patients with APD.
- Research suggests that the generalized subtype of SAD and the considerable overlap
of the APD diagnosis are associated with severe levels of social anxiety, poor overall
psychosocial functioning, greater overall psychopathology, high trait anxiety, and
depression.
- Many researchers have questioned the utility of maintaining two diagnostic
categories. Consequently, it has been suggested that both diagnostic groups may only
differ in the extent of severity.
o Therefore, on one side of the continuum the specific (nongeneralized) SAD
diagnosis most likely reflects the slightest manifestation of social anxiety.
Progressively the continuum leads to a more severe indication of social
anxiety, such as the generalized SAD subtype without (APD). And on the other
side of the continuum the generalized SAD with APD illustrates a more severe
expression of the disorder.
Several studies have also examined comorbidity between SAD and other disorders such as body
dysmorphic disorder (BDD), psychosis, bipolar disorder, and eating disorders.
, 2. Overlap between BDD and SAD: both disorders have similar core features, such as
embarrassment, rejection, and avoidance of social situations. BDD patients with
comorbid diagnosis of SAD have greater lifetime history of suicidal ideation, poor
social adjustment, and are less likely to be employed compared with those without
comorbid SAD.
3. Comorbidity between SAD and psychotic disorders (especially with schizophrenia 11%
- 39%). Psychotic patients with social anxiety symptoms have more severe psychotic
symptoms, a lower quality of life, and lower social adjustment.
4. Relationships between SAD and bipolar spectrum disorders (4.2% to 20%).
5. Overlap between anxiety and eating disorders (18% - 23%). Comorbidity rates are
higher for anorexia and bulimia patients. SAD might be one of the etiological pathways
for developing eating disorders, as the onset of the disorder usually occurs earlier in
the majority of cases.
In conclusion, SAD comorbidity is prevalent and appears to be a marker of greater symptom severity
and functional impairment for patients suffering from the disorder.
Epidemiology
- 12-month prevalence rate of SAD among adults is 7.1-7.9%.
- Considerable cultural differences in prevalence rate and expression of SAD.
- Males and females are affected almost equally by this disorder with an average ratio
of 1:1 and 3:2 (female:male).
- Onset is usually in the mid-teens, but it can be seen in early childhood. It can be
diagnoses reliably at the age of 6. Childhood and adolescence might be the main
developmental stages for impermanent social anxieties to appear. During childhood,
SAD is often related to separation anxiety, anxiety-related disorders, mutism, shyness,
school refusal, behavioral inhibition, and overanxious disorder.
- Seems more common in younger people; highest lifetime prevalence rates observed
among the youngest individuals and lowest rates among the oldest individuals (could
reflect recall failure or problems in reporting accuracy).
- SAD is seen more among unmarried individuals.
Illness course and impairment
Individuals with SAD often experience a variety of psychosocial problems, such as difficulties in finding
a job, attending school, or getting married. The disorder typically follows a chronic and unremitting
course without treatment. SAD has fairly stable course during the lifetime → could lead to a reduced
quality of life and total isolation.
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