Social Anxiety Disorder (S.A.D)

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al Anxiety Disorder (S. BY DR. IBTIHAL MOHAMED ALY ASS. LECTURER PSYCHIATRY DEPARTMENT

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Social Anxiety Disorder (S.A.D). By Dr. Ibtihal Mohamed Aly Ass. Lecturer Psychiatry Department. Definition:. - PowerPoint PPT Presentation

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Page 1: Social Anxiety Disorder (S.A.D)

Social Anxiety Disorder (S.A.D)BY

DR. IBTIHAL MOHAMED ALYASS. LECTURER PSYCHIATRY DEPARTMENT

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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.

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Associated features of social anxiety disorder

poor social skillsnegative

evaluationdifficulty of

being assertive

hypersensitivity to criticism

low self-esteem and feelings of inferiority

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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

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•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:

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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.

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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.

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Epidemiology:

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DSM-IV Diagnostic Criteria:

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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

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CLINICAL PICTUREIbtihal M.A. Ibrahim

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Symptoms

Cognitive

Behavioral

Physiological

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Behavioral symptoms:Escape

avoidance behaviors

Controlled byMajor

avoidance behaviors

Minor avoidance behaviors Ibtihal M.A. Ibrahim

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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

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ETIOLOGY

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Biological

•Genetic and family factors•Neural mechanisms.•Neuroanatomical.

Psychologic

al

•Cognitive context.•Evolutionary context.

Social

• Social experiences

• Social/cultural influences

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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.

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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

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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.

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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.

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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'

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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

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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.

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Co-morbidityIbtihal M.A. Ibrahim

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Axis I• Other anxiety disorders.

• Depression.• Bipolar disorder.

• Substance use disorders.• Eating disorders.

Axis II• Avoidant

personality disorder (APD).

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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

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TREATMENTIbtihal M.A. Ibrahim

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Psychotherapy

Combination

Pharmacotherapy

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PHARMACOTHERAPYIbtihal M.A. Ibrahim

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MAOIs Benzodiazepines

SSRIs SNRIs

β- Blocker

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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

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psychotherapy

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CBT

Exposure

Applied relaxationSocial skills training

Cognitive restructuring

Cognitive Behavioral Group

Therapy(CBGT)

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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

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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.

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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

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Cognitive restructuring:

Identify

negative

thoughts

Evaluate the

accuracy of their

thoughts

Derive rational alterna

tive though

ts

In cognitive restructuring, individuals are taught to:

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Cognitive-Behavioral Group Therapy:

6patients

2.5hours

12weeks

1&2sessions

rationale

instructions

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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.

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Thank You

Ibtihal M.A. Ibrahim