Prevalence of Social Phobia in school-going adolescents in an urban area

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
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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,
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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
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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
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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.
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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
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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
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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
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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
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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.
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