DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 APRIL 2009 Ravi Pandey Memorial Award Paper Prevalence of Social Phobia in school-going adolescents in an urban area Vishal Chhabra, MS Bhatia, Sahil Gupta, Pankaj Kumar, Shruti Srivastava Department of Psychiatry, UCMS & GTB Hospital, Dilshad Garden, Delhi-110095, University of Delhi Introduction Social phobia is defined by DSM-IV-TR as an anxiety disorder characterized by a strong and persistent fear of social or performance situations in which the patient might feel embarrassment or humiliation. Social phobia, which is also known as social anxiety disorders, is a serious mental health problem in India with an incidence of 2.79% and prevalence of 1.47 %1,2. Patients diagnosed with social phobia have the highest risk of alcohol abuse among all patients with anxiety disorder. The onset of social phobia almost always occurs in childhood or the mid teens; onset after the age 25 is unusual. The disorder is often a lifelong problem, although its severity may diminish in adult life. Adults and adolescents with social phobia, as well as many children with the disorder, have sufficient insight to recognize that their fears are excessive and unwanted. This factor often adds to their distress and feelings of inferiority. Social phobia is of major concern to society as a whole for two reasons. One reason is the disorder’s very high rate of co morbidity with such other mental health problems as major depression and substance abuse. The second is the loss to the larger society of the gifts and talents that these patients possess. Thereby, early diagnosis of this condition is imperative. The causes3 of social phobia appear to be a combination of biological, psychological and environmental factors1. Neurobiological Factors — a group of researchers at Yale has identified a genetic locus on human chromosome 3 that is linked to agoraphobia. In addition, researchers at the National Institute of Mental Health have identified a gene in mice that appears to govern fearfulness. By 18 Positron Emission Tomography (PET) scans, researchers have concluded that patients with social phobia have a different neurochemical response to certain social situations or challenges that activates the limbic system rather than the cerebral cortex. 2. Temperament — a number of researchers have pointed to inborn temperament (natural pr edisposition) as a broad vulnerability factor in the development of anxiety and mood disorders. Children who manifest what is known as behavioral inhibition in early infancy are at increased risk for developing more than one anxiety disorder in adult life, particularly if the inhibition remains over time. Behavioral inhibition refers to a group of behaviors that are displayed when the child is confronted with a new situation or unfamiliar people. These behaviors include moving around, crying, and general irritability, followed by withdrawing, seeking comfort fro a familiar person, and stopping what one is doing when one notices the new person or situation. Children of depressed or anxious patients ar e more likely to develop behavioral inhibition. 3. Psychological Factors — the development of social phobia is also influenced by parent-child interactions an a patient’s family origin. Symptoms in Children3 : Symptoms of social phobia in children frequently include tantrums, crying, “freezing”, clinging to parents or other familiar people and inhibiting interactions to the point of refusing to talk to others (mutism). Symptoms in Adults : the symptoms of social Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society APRIL 2009 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 phobia in adults include a range of physical signs of anxiety as well as attitudes and behaviors. Blushing, sweating, nausea, diarrhea, dry mouth, tremors, and other physical indications of anxiety, difficulties with self assertion, extreme sensitivity to criticism, rejection, or negative evaluations, intense preoccupation with the reactions and responses of others, heightened fears of being embarrassed or humiliated, avoidance of the feared situation(s) and anticipatory anxiety. In adults, there is often a “vicious circle” quality to the symptoms, in that anxiety and symptoms lead to actual or perceived poor performance, which in turn increase the anxiety and avoidance. Demographics Surveys of adults in the general population indicate that most people diagnosed with social phobia are afraid of public speaking; only 45% report being afraid of meeting new people or having talk to strangers. Fears related to eating, drinking, or writing in public, or using a public restroom, are much less common in these group of patients. By contrast, people being treated for social phobia in outpatient clinics are more likely to be afraid of a range of social situations rather than just one. Social phobia accounts for 10%-20% of the anxiety disorders diagnosed in patients in outpatients clinics. Community - based studies suggest that social phobia is more common in women, but in most samples of clinical patients, the sex ratio is either equal or males are in the majority. Diagnosis The diagnosis of social phobia is usually made on the basis of the patient’s history and reported symptoms. The clinician can also administer various scales and inventories for screening and diagnosing social anxiety disorder e.g. Liebowitz Social Anxiety Scale for children and adolescents, or LSAS-CA, the Child Development Inventory or CDI and the Social Phobia and Anxiety Inventory for Children, or SPAI-C4 in children and Structured Clinical Interview for DSM-IV Screen (SCIDScreen), Primary Care Evaluation of Mental Disorders , or Prime –MD and the Liebowitz Social Anxiety Scale5, 6 in adults. The prognosis for recovery from social phobia is good, given early diagnosis and appropriate treatment. The prognosis for persons with untreated social phobia, however, is poor. In most cases, these individuals become long term underachievers , at high risk for alcoholism, major depression and suicide. Given that some of the factors implicated in social phobia are neurobiological or genetic, the best preventive strategy is early identification of children with behavioral inhibition and developing techniques for assisting their social development. Thereby, early diagnosis at school age is imperative, and this study will help to this cause. Review of Literature Many studies have been done on social phobia using Liebowitz Social Anxiety Scale (LSAS).5, 6 A study named “Psychometric properties of the Liebowitz Social Anxiety Scale” by Heimberg R.G. and Liebowitz M.R. et al demonstrated the high construct reliability (0.94) and its usefulness in clinical assessment. Melfsen S, Walitza et al8 conducted a study in Germany titled “The extent of social anxiety in combination with mental disorders”. It clearly showed the association between anxiety and other mental disorders. Patients who had the following mental disorders also showed a higher total score of social anxiety: obsessive compulsive disorder, anorexia nervosa, schizophrenia, depression and conduct disorder. Studies also revealed the relation between stress disorders and anxiety9 and also that eating related attitudes and behavior are associated with high levels of social anxiety.10 LSAS5, 6 is a clinician administered test that has been used in many studies and is available in a standardized form for children. LSAS performed well in identifying individuals who met criterion for SAD and for the generalized subtype of SAD13. LSAS has also been used to test the prognosis, which clearly depicts its reliability among the practitioners. By administering the validated LSAS to children of the age group 14-17 years, the incidence of social phobia can be detected ant the disease can be diagnosed while it still can be treated easily14, 15 Since the targets of our study were children and LSAS is one of the most valid and reliable test, Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society 19 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 it was used in this study. As of now, very less work has been done in the field of social anxiety in India especially in adolescents; this study will therefore help in collecting the data and analyzing the incidence of social anxiety disorder. As social anxiety disorder is also related to other more dangerous and incapacitating disorders. The screening of social anxiety in children assumes even a greater importance especially in this world of competition, where an individual is at an increased risk of getting stressed up and developing major psychiatric disorders including social anxiety. This study will help in diagnosing the disorder of social phobia or social anxiety at an early stage. It has been already said that early diagnosis, means good prognosis. In early stages of this disorder, only cognitive behavioral therapy may benefit the patient and after a brief treatment, the patient may lead a healthy life. However, if the diagnosis and treatment are delayed, then not only the patient will lose a major part of his life but also the treatment becomes more difficult and prognosis is poor. This study is thus concentrating on children and adolescents. This study will thereby help individuals to regain control over their lives and in turn benefiting the society as a whole. Aims and Objectives 1. To assess the incidence of social anxiety disorder in school going children in the age group of 14-17 years. Materials and Methods Inclusion Criterion : 1. Children in the age group of 14-17yr attending school 2. Both male and female students were included. Exclusion Criterion 1. Children outside the age group. 2. Children who refuse to give consent for the participation. The Liebowitz Social Anxiety Scale will be used as the diagnostic module. It has been previously validated and tested in number of populations. It basically consists of 24 items. Its 24 items are divided into two subscales that address social interaction (11 items) and performance (13 20 APRIL 2009 items) situations. The clinician asks the patient to rate fear and avoidance during the past week on 03 likert-type scale. It uses a likert like scale, which is based on the frequency with which these symptoms are experienced by the patient. Thus, the LSAS provides six subscale scores: total fear, fear of social interaction, fear of performance, total avoidance, avoidance of social interaction and avoidance of performance. An overall total score is often calculated by summing the total fear and total avoidance scores. The high validity and reliability of the scale is one of the key features5. The LSAS Performa was given to 300 school children between the age of 14-17 years, in the class 8th-11th A time of 45 minutes was allotted to the children. Assistance could be taken during the procedure. The informed consent was taken from the principal of the school. Each student was given the doctor’s number for further workup, if needed. Any student who faced any difficulty in filling up the performa was helped and encouraged to fill the complete performa. The performa was collected from the students after 45 minutes. Incomplete performa, if received, the student was encouraged to complete it, and otherwise, the performa was discarded and not included. The statistical analysis was done using SPSS statistical software using appropriate statistical tests. Results Section-1. Demographic features. Age, Class and gender distribution of the sample of population under study. Table - 1.1: Age Distribution Age Frequency Percent (years) Valid Cumulative Percent Percent 14 15 16 17 159 55 62 25 52.8 18.3 20.6 8.3 52.8 18.3 20.6 8.3 Total 301 100.0 100.0 52.8 71.1 91.7 100.0 The incidence of social anxiety in this sample of the population of school going children under the age group 14-17 years was found out to be 10.3%, in which 5% belonged to the moderate category, 4.3% to the marked, 0.7% to the severe Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society APRIL 2009 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 MALE=1 FEMALE=2 Figure 1.3 Gender Distribution Figure 1.1 Age Distribution Table 1.4 Statistics Table 1.2: Classwise Distribution Class Frequency Percent Valid Cumulative Percent Percent 8 9 10 11 113 50 69 69 37.5 16.6 22.9 22.9 37.5 16.6 22.9 22.9 Total 301 100.0 100.0 37.5 54.2 77.1 100.0 N Age Class Sex Valid Missing Mean Std. Deviation 301 0 14.84 1.02 301 0 9.31 1.20 301 0 1.31 .46 SECTION 2. LSAS SCORE DISTRIBUTION Figure 1.2 Class Distribution Figure 2.1 LSAS Score distribution Table 1.3 Gender Distribution Sex Frequency Percent Valid Cumulative Percent Percent Male=1 207 Female=2 94 68.8 31.2 68.8 31.2 Total 100.0 100.0 301 68.8 100.0 and 0.3% to the very severe social anxiety category. Rest of the 89.7% population was in the normal range (p<0.05). (Table 2.2) The age Distribution clearly showed that the level of social anxiety was higher in children in their early teens, standing at 11.94% in 14 years Figure 3.1 Pre syndromal cases. Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society 21 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 APRIL 2009 Table-2.1: Case Processing Summary Cases Valid AGE * total LSAS score GENDER * total LSAS score Missing Total N Percent N Percent N Percent 301 301 100.0% 100.0% 0 0 .0% .0% 301 301 100.0% 100.0% Table-2.2: Total LSAS Score Category Frequency Percent Valid Percent Cumulative Percent Below the cutoff/normal Moderate social anxiety Marked social anxiety Severe social anxiety Very severe social anxiety 270 15 13 2 1 89.7 5.0 4.3 .7 .3 89.7 5.0 4.3 .7 .3 Total 301 100.0 100.0 89.7 94.7 99.0 99.7 100.0 Table-2.3: Age - LSAS score Crosstabulation Age Total LSAS score below the cut off/normal moderate social anxiety Total marked social anxiety severe social anxiety very severe social anxiety 14 15 16 17 140 47 58 25 10 3 2 0 7 4 2 0 2 0 0 0 0 1 0 0 159 55 62 25 Total 270 15 13 2 1 301 Table-2.4: Sex -LSAS score Crosstabulation GENDER Total LSAS score below the cut off/normal moderate social anxiety marked social anxiety Total severe social anxiety very severe social anxiety Male=1 Female=2 187 83 9 6 10 3 1 1 1 207 94 Total 270 15 13 2 1 301 old,17.02% in 15 years,6.4% in 16 years and 0.0% in 17 years old children (p < 0.05).(Table 2.3) The gender distribution also showed higher incidence of social anxiety among girls, standin at 11.702% with respect to 9.66% in boys (p < 0.05). (Table 2.4) When the pre syndromal stage was also taken 22 into consideration, it showed that a staggering 34.2% of the sample population was at the risk of developing the clinical disease (p < 0.05). (Table 3.1) Discussion The incidence of social anxiety disorder in the sample of the population was 10.3%, which is Delhi Psychiatry Journal 2008; 12:(1) © Delhi Psychiatric Society APRIL 2009 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 SECTION 3.Demography of the pre syndromal population. Table 3.1 Distribution showing the percentage of sample population in the pre syndromal stage. Category Frequency Percent Valid Percent below 45 (normal) 45-54 (pre syndromal) more than 54 (overt disease) 167 103 31 55.5 34.2 10.3 55.5 34.2 10.3 Total 301 100.0 100.0 Cumulative Percent 55.5 89.7 100.0 SECTION 4. Independent Samples Test Table 4.1 Independent Samples Test t-test for Equality of Means t COMPLET LSAS SCORE LSAS ANXIETY LSAS AVOIDANCE df Sig. Mean (2-tailed) Difference Std. Error 95% Confidence DiffeInterval of the rence Difference Lower Upper Equal variances assumed -.491 212 .624 -1.06 2.17 -5.33 3.21 Equal variances not assumed -.467 86.576 .641 -1.06 2.27 -5.58 3.46 Equal variances assumed .252 212 .801 .30 1.17 -2.01 2.61 Equal variances not assumed .254 95.243 .800 .30 1.16 -2.01 2.60 Equal variances assumed -1.150 212 .252 -1.36 1.18 -3.69 .97 Equal variances not assumed -1.036 79.653 .303 -1.36 1.31 -3.97 1.25 roughly 3 times the figure in India of 2.79%.1, 2 The onset of social phobia is in the mid teens and thereby scanning school children gives us a greater chance of identifying the patients and treating them early, when the disease has still not incapacitated the individual.7, 14, 15 Out of the 10.3% population, most belonged to the moderate and marked social anxiety category, the percentage of children belonging to the severe and very severe group was very less (1%) which might be due the high drop out rate among these children and high absenteeism as these children often avoid social situations and often fail to seek psychiatric help and remain undiagnosed till it has incapacitated them. Since the study was carried out on the children of local government school, where the families of the children are not well off economically and the parents not that much educated, these children have a greater risk of developing social phobia. Also because the poor level of education in the schools and lack of adequate care and attention on the part of teachers, the child continues to face this disorder alone, unable to do so, the child is caught in a vicious cycle, where social phobia causes failure to respond to challenges and this in turn predisposes him to social phobia. The age Distribution clearly showed that the level of social anxiety was higher in children in their early teens, standing at 11.94% in 14years old, 17.02% in 15 years, 6.4% in 16 years and 0.0% in Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society 23 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 17 years old children. This shows that the incidence of social anxiety is high in the mid teens.7 Social anxiety disorder is caused by the longerterm effects of not fitting in, or being bullied, rejected or ignored. Shy adolescents or avoidant adults have emphasized unpleasant experiences with peers or childhood bullying or harassment.16 Popularity is found to be negatively correlated with social anxiety, and children who are neglected by their peers report higher social anxiety and fear of negative evaluation than other categories of children. In their teens only, when children learn to take up different roles in their family, peers, social circles, any of the above mentioned circumstances can lead to the advent of social phobia in child. If the child is unable to face these challenges, and adapt to the new roles, the child eventually lands up developing social phobia. People suffering from social anxiety also have the high chances to develop other disorders like OCD, anorexia nervosa, Schizophrenia, Depression. 8 These children also had greater chances of developing other diseases like alcohol abuse,17 panic disorder (33%), generalized anxiety disorder (19%), post traumatic stress disorder (36%), substance abuse disorder (25%), and attempted suicide (23%).18 These disorders are also more common in the middle teens in childhood and their roots are closely linked with social phobia. The sex ratio of the children suffering from social anxiety disorder in our sample clearly showed that the females clearly exceeded the number of males which is in accordance with the study carried by R.G. Heimberg et al19 in which the ratio of males: females was 1 : 1.5. This can be because of the face that males are able to seek help for their disorder when compared to females and in Indian society, more care is given to the male child. Thereby in most samples of clinical patients, the sex ratio is either 1:1 or males are in the majority. Female health is generally ignored in a developing country like India. Since females are in the majority when it comes to social phobia, early diagnosis by screening in school children, active surveillance and case detection are of utmost importance in curbing this disorder. Also, the role of family and school in bringing up the child needs to be strengthened. If we have a look at the subset of the sample population having the pre syndromal disease or who 24 APRIL 2009 are at high risk of developing the disease, it was found that 34.2% of the population was at a high risk. A previous negative social experience can be a trigger to social phobia. perhaps particularly for individuals high in ‘interpersonal sensitivity’. For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder.20, 21, 22 Thereby it wont be wrong to say that if this subset of population is exposed to repeated blows to one’s self esteem and other negative experiences, these children can also develop the clinical disease, making the incidence rise from 10.3% to a staggering 44.5%. Thereby diagnosing and treating the children in the pre syndromal phase is also a good tool in curbing the incidence of social phobia. The experimental design was successful in deciphering the incidence of social anxiety in the population and also helpful in identifying the high risk individuals. LSAS is an appropriate tool to investigate social phobia. The high reliability and construct validity confer LSAS the ability to serve not only as the diagnostic tool, but also as a screening modality and a prognosis indicator. Comparing the results of children from a government school with the results got from children from a good private school where the family background and efficiency of teachers is definitely better than that of a government school will give us a better insight into the incidence and the aetiopathogenesis of the social anxiety disorder. Long term follow up of these children can also help us recognize other causal and predisposing factors. Also these children, both with overt disease and in pre syndromal stage,should be screened for other psychiatric disorders. Conclusions The incidence of social anxiety disorder in a Government school children of the age group was 10.3%. Females showed a higher incidence of social phobia when compared to males, and children in the age group of 14–15 years had a higher incidence of social phobia than those of the age group 16–17 years. The percentage of the sample in the pre syndromal category or those in the high risk category was 34.2%, clearly stating that the Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society APRIL 2009 DELHI PSYCHIATRY JOURNAL Vol. 12 No.1 diagnosed cases only represented the tip of the iceberg. Since the incidence of overt disease is high, adequate measures need to be taken to reverse the process as most of the cases belonged to the moderate and marked category which can be easily treated with medications and cognitive behavioral therapy. Also the pre syndromal cases can be taken up for proper counseling so they do not develop the disease. Health education, not only of students, but teachers and family members can be of great importance and give us a great impetus in curbing the disease. These steps if taken early, can lead to a better prognosis. Further research should be done on different subsets of children, differing in only one variable, so as to establish the definite causal relationship of the variable with the disease. These children should be screened for other associated disorders. Other diagnostic modules can also be used to aid LSAS in diagnosing, screening and predicting the prognosis of the cases. References 1. US Census Bureau. Population estimation study, 2004. 2. US Census Bureau, International Database, 2004. 3. Beidel DC. Social anxiety disorder: Etiology and early clinical presentation. J Clin Psychiatry 1988; 59 : 27 – 31. 4. S.M. Turner and D.C. Beidel. “Validation of the Social Phobia and Anxiety Inventory for Children (SPAI-C) in a sample of Brazilian children”. SPAI-C validation in Brazilian J Med Biol Res 2005; 38 : 795 – 800. 5. R.G. Heimberg, Michael R. Liebowitz et al. “Psychometric properties of the Liebowitz Social Anxiety Scale”. Psychol Med 1999; 29 : 199 – 212. 6. Richard G. Heimberg, Michael R. Liebowitz et al. “Screening for social anxiety disorder in the clinical setting: using the Liebowitz Social Anxiety Scale” J Anxiety Disord 2002; 16(6) : 661 – 673. 7. Social Anxiety Disorder. www.wikepedia.com. 9. Beidel DC, Turner SM et al. “Self reported symptoms of social anxiety in a sample of combat veterans with post traumatic stress disorder”. J Anxiety Disorder 1998; Nov. -Dec.: 605-612. 10. Hinrichsen H, Waller G, Emanvelli F. “Social anxiety and agoraphobia in the eating disorders: associa-tions with eating attitude and behaviors.” J Nerv Dis 2004; 192 : 784 – 784. 11. Beidel DC. Social phobia and over-anxious disorders in school age children. J Am Acad Child Adoles Psychiatry 1991; 30 : 545 – 552. 12. Francis G,Last CG and Strauss CC. “Avoidant disorder and social phobia in children and adolescent. J Am Acad Child Adoles Psychiatry 1992; 31 : 1086 – 1089. 13. Psychiatry Congress Paxil. Effective treatment for Social Anxiety Disorder. Hamburg, Germany. Psychopharmacol Bull 37 : 167 – 175. 14. Beidel DC and Turner SM. Shy children, phobic adults:Nature and treatment of Social Phobia. J Clin Psychiatry 1998; 59 : 27 – 31. 15. Nathan PE, Gorman JM. A guide to treatments that work. Oxford University Press, New York 1998. 16. Ishiyama F. Shyness: Anxious Social Sensitivity and Self isolating tendency 1984; 19 : 903 – 911. 17. Sarah WB et al. Social Anxiety disorder and Alcohol Abuse. Alcohol Res Heath February 2006. 18. Crozier, page 361. 19. Heimberg RG. Social phobia: Diagnosis Assessment ant treatment, Gulford press 1995; pp 29 – 30. 20. National Centre for Health and Wellness. Causes of Social Anxiety Disorder. February 2006. 21. Athealth.com. Social phobias, February 2006. 22. Mineka S, Zinbarg R. Conditioning and Ethological models of Social Phobia. Gulford Press 1995; pp 134 – 162. Delhi Psychiatry Journal 2009; 12:(1) © Delhi Psychiatric Society 25