social anxiety disorder

社会不安障害

関

social phobia

WordNet

1. tending to move or live together in groups or colonies of the same kind; "ants are social insects"
2. relating to human society and its members; "social institutions"; "societal evolution"; "societal forces"; "social legislation" (同)societal
3. composed of sociable people or formed for the purpose of sociability; "a purely social club"; "the church has a large social hall"; "a social director"
4. living together or enjoying life in communities or organized groups; "a human being is a social animal"; "mature social behavior"
5. marked by friendly companionship with others; "a social cup of coffee"
6. relating to or belonging to or characteristic of high society; "made fun of her being so social and high-toned"; "a social gossip colum"; "the society page"
7. bring disorder to (同)disarray
8. a physical condition in which there is a disturbance of normal functioning; "the doctor prescribed some medicine for the disorder"; "everyone gets stomach upsets from time to time" (同)upset
9. a disturbance of the peace or of public order
10. (psychiatry) a relatively permanent state of worry and nervousness occurring in a variety of mental disorders, usually accompanied by compulsive behavior or attacks of panic (同)anxiousness
11. a vague unpleasant emotion that is experienced in anticipation of some (usually ill-defined) misfortune
12. not arranged in order (同)unordered

PrepTutorEJDIC

1. 『社会の』,社会的な / 『社交界の』,上流社会の / 《名詞の前にのみ用いて》『社交の』,親睦(しんぼく)の / (アリ・ハチなどが)群居する / 親睦(しんぼく)会,懇親会
2. 〈U〉『無秩序』,混乱,乱雑(confusion) / 《しばしば複数形で》(社会的・政治的な)粉争,騒動 / 〈C〉(肉体的・精神的な)不調,異常,障害 / …‘の'秩序を乱す / 〈心身〉‘に'異常を起こさせる
3. 〈U〉(…についての)『心配』,不安,気がかり《+『about(for)』+『名』》 / 〈C〉心配事,心配の種 / 〈U〉《話》『切望』,熱望;〈C〉切望する事(物)

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2016/06/01 18:32:06」(JST)

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Social anxiety disorder
Classification and external resources
Specialty	psychiatry
ICD-10	F40.1, F93.2
ICD-9-CM	300.23
MedlinePlus	000957
Patient UK	Social anxiety disorder
MeSH	D010698

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by a significant amount of fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life. These fears can be triggered by perceived or actual scrutiny from others. It is the most common anxiety disorder and one of the most common psychiatric disorders, with 12% of American adults having experienced it.

Physical symptoms often accompanying social anxiety disorder include excessive blushing, excess sweating, trembling, palpitations and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. It is common for sufferers of social phobia to self-medicate in this fashion, especially if they are undiagnosed, untreated, or both; this can lead to alcoholism, eating disorders or other kinds of substance abuse. SAD is sometimes referred to as an 'illness of lost opportunities' where 'individuals make major life choices to accommodate their illness.' According ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. Standardized rating scales can be used to screen for social anxiety disorder and measure the severity of anxiety.

The first line treatment for social anxiety disorder is cognitive behavioral therapy with medications recommended only in those who are not interested in therapy. Cognitive behavioral therapy is effective in treating social phobia, whether delivered individually or in a group setting. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxiety-inducing situations. The attention given to social anxiety disorder has significantly increased since 1999 with the approval and marketing of drugs for its treatment. Prescribed medications include several classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). Other commonly used medications include beta blockers and benzodiazepines.

Signs and symptoms

Cognitive aspects

In cognitive models of social anxiety disorder those with social phobias experience dread over how they will be presented to others. They may feel overly self-conscious, pay high self-attention after the activity, or have high performance standards for themselves. According to the social psychology theory of self-presentation, a sufferer attempts to create a well-mannered impression towards others but believes he or she is unable to do so. Many times, prior to the potentially anxiety-provoking social situation, sufferers may deliberately review what could go wrong and how to deal with each unexpected case. After the event, they may have the perception that they performed unsatisfactorily. Consequently, they will perceive anything that may have possibly been abnormal as embarrassing. These thoughts do not simply terminate soon after the encounter, but may extend for weeks or longer. Cognitive distortions are a hallmark, and are learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and many studies suggest that socially anxious individuals remember more negative memories than those less distressed.

An example of an instance may be that of an employee presenting to his co-workers. During the presentation, the person may stutter a word, upon which he or she may worry that other people significantly noticed and think that their perceptions of him or her as a presenter have been tarnished. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a panic attack.

Behavioral aspects

Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include almost any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, interviews etc.

Those who suffer from social anxiety disorder fear being judged by others in society. In particular, individuals with social anxiety are nervous in the presence of people with authority and feel uncomfortable during physical examinations. People who suffer from this disorder may behave a certain way or say something and then feel embarrassed or humiliated after. As a result, they choose to isolate themselves from society to avoid such situations. They may also feel uncomfortable meeting people they do not know, and act distant when they are with large groups of people. In some cases they may show evidence of this disorder by avoiding eye contact or blushing when someone is talking to them.

According to psychologist B.F. Skinner, phobias are controlled by escape and avoidance behaviors. For instance, a student may leave the room when talking in front of the class (escape) and refrain from doing verbal presentations because of the previously encountered anxiety attack (avoid). Major avoidance behaviors could include an almost pathological/compulsive lying behavior in order to preserve self-image and avoid judgement in front of others. Minor avoidance behaviors are exposed when a person avoids eye contact and crosses his/her arms to avoid recognizable shaking. A fight-or-flight response is then triggered in such events.

Physiological aspects

Physiological effects, similar to those in other anxiety disorders, are present in social phobics. In adults, it may be tears as well as excessive sweating, nausea, difficulty breathing, shaking, and palpitations as a result of the fight-or-flight response. The walk disturbance (where a person is so worried about how they walk that they may lose balance) may appear, especially when passing a group of people. Blushing is commonly exhibited by individuals suffering from social phobia. These visible symptoms further reinforce the anxiety in the presence of others. A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

Comorbidity

SAD shows a high degree of comorbidity (co-occurrence) with other psychiatric disorders. In fact, a population-based study found that 66% of those with SAD had one or more additional mental health disorders. SAD often occurs alongside low self-esteem and clinical depression, perhaps due to a lack of personal relationships and long periods of isolation related to avoidance of social situations. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance abuse. It is estimated that one-fifth of patients with social anxiety disorder also suffer from alcohol dependence. However, some research suggests SAD is unrelated to, or even protective against, alcohol-related problems. One of the most common complementary psychiatric conditions is depression, with clinical depression being 1.49 to 3.5 times more likely to occur in those with SAD. Aside from depression, other common disorders diagnosed in patients with SAD are other anxiety disorders, in particular generalized anxiety disorder. Avoidant personality disorder is also highly correlated with SAD, with comorbidity rates ranging from 25% to 89%. Patients who suffer from both alcoholism and social anxiety disorder are more likely to avoid group-based treatments and are more likely to relapse compared to people who do not have both disorders simultaneously.

The DSM-IV criteria stated that an individual cannot receive a diagnosis of social anxiety disorder if their symptoms are better accounted for by one of the autism spectrum disorders such as autism and Asperger syndrome.

Because of its close relationship and overlapping symptoms with other illnesses, treating people with social phobia may help understand underlying connection in other psychiatric disorders. There is research indicating that social anxiety disorder is often correlated with bipolar disorder and attention deficit hyperactivity disorder. Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition. In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls. The hypomania can be seen as the medication creating a new problem.

Causes

Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors. Social phobia is not caused by other mental disorders or by substance abuse. Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia.

Genetics

It has been shown that there is a two to threefold 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 or parental psychosocial education. 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 percent and 50 percent more likely than average to also develop the disorder. To some extent this 'heritability' may not be specific – for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves (Bruch and Heimberg, 1994; Caster et al., 1999), and shyness in adoptive parents is significantly correlated with shyness in adopted children (Daniels and Plomin, 1985);

Growing up with overprotective and hypercritical parents has also been associated with social anxiety disorder. Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, including social phobia.

A related line of research has investigated 'behavioural inhibition' in infants – early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10–15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait into adolescence and adulthood, and appear to be more likely to develop social anxiety disorder.

Social experiences

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; this kind of event appears to be particularly related to specific (performance) social phobia, for example regarding public speaking (Stemberg et al., 1995). As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers, may also make the development of a social anxiety disorder more likely. Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being bullied, rejected or ignored (Beidel and Turner, 1998). Shy adolescents or avoidant adults have emphasised unpleasant experiences with peers or childhood bullying or harassment (Gilmartin, 1987). In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children. Socially phobic children appear less likely to receive positive reactions from peers and anxious or inhibited children may isolate themselves.

Cultural influences

Cultural factors that have been related to social anxiety disorder include a society's attitude towards shyness and avoidance, affecting the ability to form relationships or access employment or education, and shame. One study found that the effects of parenting are different depending on the culture – American children appear more likely to develop social anxiety disorder if their parents emphasize the importance of others' opinions and use shame as a disciplinary strategy (Leung et al., 1994), but this association was not found for Chinese/Chinese-American children. 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. Purely demographic variables may also play a role.

Problems in developing social skills, or 'social fluency', may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills while others have. What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the 'middle classes'. An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety.

Substance induced

While alcohol initially relieves social phobia, excessive alcohol misuse can worsen social phobia symptoms and can cause panic disorder to develop or worsen during alcohol intoxication and especially during alcohol withdrawal syndrome. This effect is not unique to alcohol but can also occur with long term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquillisers. Benzodiazepines possess anti-anxiety properties and can be useful for the short-term treatment of severe anxiety. Like the anticonvulsants, they tend to be mild and well tolerated, although there is a risk of habit-forming. Benzodiazepines are usually administered orally for the treatment of anxiety; however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks.

The World Council of Anxiety does not recommend benzodiazepines for the long term treatment of anxiety due to a range of problems associated with long term use including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and a benzodiazepine withdrawal syndrome upon discontinuation of benzodiazepines. Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety, benzodiazepines have remained a mainstay of anxiolytic pharmacotherapy due to their robust efficacy, rapid onset of therapeutic effect, and generally favorable side effect profile. Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder.

Approximately half of patients attending mental health services for conditions including anxiety disorders such as panic disorder or social phobia are the result of alcohol or benzodiazepine dependence. Sometimes anxiety pre-existed alcohol or benzodiazepine dependence but the alcohol or benzodiazepine dependence act to keep the anxiety disorders going and often progressively making them worse. Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol and/or their benzodiazepines. It was noted that every individual has an individual sensitivity level to alcohol or sedative hypnotic drugs and what one person can tolerate without ill health another will suffer very ill health and that even moderate drinking can cause rebound anxiety syndromes and sleep disorders. A person who is suffering the toxic effects of alcohol or benzodiazepines will not benefit from other therapies or medications as they do not address the root cause of the symptoms. Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.

Psychological factors

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. One line of work has focused more specifically on the key role of self-presentational concerns. The resulting anxiety states are seen as interfering with social performance and the ability to concentrate on interaction, which in turn creates more social problems, which strengthens the negative schema. Also highlighted has been a high focus on and worry about anxiety symptoms themselves and how they might appear to others. A similar model emphasizes the development of a distorted mental representation of the self and overestimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Such cognitive-behavioral models consider the role of negatively biased memories of the past and the processes of rumination after an event, and fearful anticipation before it. Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use 'safety behaviors' (Clark & Wells, 1995) can make social interaction more difficult and the anxiety worse in the long run. This work has been influential in the development of Cognitive Behavioral Therapy for social anxiety disorder, which has been shown to have efficacy.

Mechanisms

There are many studies investigating neural bases of social anxiety disorder. Although the exact neural mechanisms have not been found yet, there is evidence relating social anxiety disorder to imbalance in some neurochemicals and hyperactivity in some brain areas.

Dopamine

Sociability is closely tied to dopamine neurotransmission. Misuse of stimulants like amphetamines to increase self-confidence and improve social performance is common. In a recent study a direct relation between social status of volunteers and binding affinity of dopamine D2/3 receptors in the striatum was found. Other research shows that the binding affinity of dopamine D2 receptors in the striatum of social anxiety sufferers is lower than in controls. Some other research shows an abnormality in dopamine transporter density in the striatum of social anxiety sufferers. However, some researchers have been unable to replicate previous findings of evidence of dopamine abnormality in social anxiety disorder. Studies have shown high prevalence of social anxiety in Parkinson's disease and schizophrenia. In a recent study, social phobia was diagnosed in 50% of Parkinson's disease patients. Other researchers have found social phobia symptoms in patients treated with dopamine antagonists like haloperidol, emphasizing the role of dopamine neurotransmission in social anxiety disorder. Also, concentration problems, mental and physical fatigue, anhedonia and decreased self-confidence can be seen in those with social anxiety disorder.

Other neurotransmitters

Some evidence points to the possibility that social anxiety disorder involves reduced serotonin receptor binding. A recent study reports increased serotonin transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder. Although there is little evidence of abnormality in serotonin neurotransmission, the limited efficacy of medications which affect serotonin levels may indicate the role of this pathway. Paroxetine and sertraline are two SSRIs that have been confirmed by the FDA to treat social anxiety disorder. Some researchers believe that SSRIs decrease the activity of the amygdala. There is also increasing focus on other candidate transmitters, e.g. norepinephrine and glutamate, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA, which may be under-active in the thalamus.

Brain areas

The amygdala is part of the limbic system which is related to fear cognition and emotional learning. Individuals with social anxiety disorder have been found to have a hypersensitive amygdala; for example in relation to social threat cues (e.g. perceived negative evaluation by another person), angry or hostile faces, and while waiting to give a speech. Recent research has also indicated that another area of the brain, the anterior cingulate cortex, which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of 'social pain', for example perceiving group exclusion. A 2007 meta-analysis also found that individuals with social anxiety had hyperactiviation in the amygdala and insula areas which are frequently associated with fear and negative emotional processing.

Diagnosis

ICD-10 defines social anxiety disorder (social phobias) as fear of scrutiny by other people leading to avoidance of social situations. The anxiety symptoms may present as a complaint of blushing, hand tremor, nausea or urgency of micturition. Symptoms may progress to panic attacks.

Standardized rating scales such as the Social Phobia Inventory, the SPAI-B, Liebowitz Social Anxiety Scale, and the Social Interaction Anxiety Scale can be used to screen for social anxiety disorder and measure the severity of anxiety.

Prevention

Focus is increasing on the prevention of anxiety disorders. Use of CBT and related techniques may decrease the number of children with social anxiety disorder following completion of prevention programs.

Treatment

Psychotherapies

The first line treatment for social anxiety disorder is cognitive behavioral therapy with medications such as selective serotonin reuptake inhibitors (SSRIs) used only in those who are not interested in therapy. Self-help based on principles of CBT is a second-line treatment.

There is some emerging evidence for the use of Acceptance and Commitment Therapy (ACT) in the treatment of social anxiety disorder. ACT Is considered an offshoot of traditional CBT and emphasizes accepting unpleasant symptoms rather than fighting against them, as well as psychological flexibility - the ability to adapt to changing situational demands, to shift one's perspective, and to balance competing desires. ACT may be useful as a second line treatment for this disorder in situations where CBT is ineffective or refused.

Some studies have suggested social skills training (SST) can help with social anxiety. Examples of social skills focused on during SST for social anxiety disorder include: initiating conversations, establishing friendships, interacting with members of the opposite sex, constructing a speech and assertiveness skills. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.

Given the evidence that social anxiety disorder may predict subsequent development of other psychiatric disorders such as depression, early diagnosis and treatment is important. Social anxiety disorder remains under-recognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as clinical depression or substance abuse disorders.

Medications

SSRIs

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are first choice medication for generalized social phobia but a second line treatment. Compared to older forms of medication, there is less risk of tolerability and drug dependency associated with SSRIs.

In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, or a placebo. The first four sets saw improvement in 50.8 to 54.2 percent of the patients. Of those assigned to receive only a placebo, 31.7 percent achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.

General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and suicidality [a term that encompasses suicidal ideation and attempts at suicide as well as suicide]. For this reason, [although evidential causality between SSRI use and actual suicide has not been demonstrated] the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder.

Other drugs

Other prescription drugs are also used, if other methods are not effective.

In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or benzodiazepines. However, because of the dietary restrictions in the amino acid tyramine required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A (RIMAs) such as the drug moclobemide, bind reversibly to the MAO-A enzyme, greatly reducing the risk of hypertensive crisis with dietary tyramine intake.

Benzodiazepines such as clonazepam are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is concern over the development of drug tolerance, dependency and misuse. It has been recommended that benzodiazepines be considered only for individuals who fail to respond to other medications. Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours. In most patients, tolerance rapidly develops to the sedative effects of benzodiazepines, but not to the anxiolytic effects. Long-term use of benzodiazepine may result in physical dependence, and abrupt discontinuation of the drug should be avoided due to high potential for withdrawal symptoms (including tremor, insomnia, and in rare cases, seizures). A gradual tapering of the dose of clonazepam (a decrease of 0.25 mg every 2 weeks), however, has been shown to be well tolerated by patients with social anxiety disorder. Benzodiazepines are not recommended as monotherapy for patients who have major depression in addition to social anxiety disorder and should be avoided in patients with a history of substance abuse.

Certain anticonvulsant drugs such as gabapentin are effective in social anxiety disorder and may be a possible treatment alternative to benzodiazepines.

Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine have shown similar effectiveness to the SSRIs. In Japan, Milnacipran is used in the treatment of Taijin kyofusho, a Japanese variant of social anxiety disorder.

The novel antidepressant mirtazapine has been studied for the treatment of social anxiety disorder, and rendered mixed results. Another atypical antidepressant, bupropion, has shown success in an open trial.

Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.

A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia. DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory.

Kava-kava has also attracted attention as a possible treatment, although safety concerns exist.

Epidemiology

Country	Prevalence
United States	2–7%
England	0.4% (children)
Scotland	1.8% (children)
Wales	0.6% (children)
Australia	1–2.7%
Brazil	4.7–7.9%
India	12.8% (adolescents)
Iran	0.8%
Israel	4.5%
Nigeria	9.4% (university students)
Sweden	15.6%
Turkey	9.6% (university students)
Poland	7-9% (2002)
Taiwan	7% child(2002~2008)

Social anxiety disorder is known to appear at an early age in most cases. Fifty percent of those who develop this disorder have developed it by the age of 11, and 80% have developed it by age 20. This early age of onset may lead to people with social anxiety disorder being particularly vulnerable to depressive illnesses, drug abuse and other psychological conflicts.

When prevalence estimates were based on the examination of psychiatric clinic samples, social anxiety disorder was thought to be a relatively rare disorder. The opposite was found to be true; social anxiety was common, but many were afraid to seek psychiatric help, leading to an underrecognition of the problem. Prevalence rates vary widely because of its vague diagnostic criteria and its overlapping symptoms with other disorders. There has been some debate on how the studies are conducted and whether the illness truly impairs the respondents as laid out in the official criteria. Psychologist Ray Crozier argues, "it is difficult to ascertain whether the person being interviewed adheres to the DSM-III-R criteria or whether they are merely exhibiting poor social skills or shyness."

The National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed 12-month and lifetime prevalence rates of 7.9 percent and 13.3 percent, respectively; this makes it the third most prevalent psychiatric disorder after depression and alcohol dependence, and the most common of the anxiety disorders. According to U.S. epidemiological data from the National Institute of Mental Health, social phobia affects 15 million adult Americans in any given year. Cross-cultural studies have reached prevalence rates with the conservative rates at 5 percent of the population. However, other estimates vary within 2 percent and 7 percent of the U.S. adult population.

The mean onset of social phobia is 10 to 13 years. Onset after age 25 is rare and is typically preceded by panic disorder or major depression. Social anxiety disorder occurs more often in females than males. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries. Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent, respectively. In Canada, the prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent). In Australia, social phobia is the 8th and 5th leading disease or illness for males and females between 15–24 years of age as of 2003. Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. The table also shows higher prevalence in Brazil.

History

Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C. Hippocrates described someone who "through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him."

The first mention of the psychiatric term social phobia (phobie des situations sociales), was made in the early 1900s. Psychologists used the term "social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research on phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist Isaac Marks, in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The definition of the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder, and introduced generalized social phobia. Social phobia had been largely ignored prior to 1985.

After a call to action by psychiatrist Michael Liebowitz and clinical psychologist Richard Heimberg, there was an increase in attention to and research on the disorder. The DSM-IV gave social phobia the alternative name social anxiety disorder. Research on the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s, paroxetine became the first prescription drug in the U.S. approved to treat social anxiety disorder, with others following.

References

Further reading

• American Psychiatric Association. (2000). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (4th ed., text rev., pp. 450–456). Washington, D.C.: American Psychiatric Association.
• Belzer K. D., McKee M. B., Liebowitz M. R. (2005). "Social Anxiety Disorder: Current Perspectives on Diagnosis and Treatment". Primary Psychiatry 12 (11): 40–53.  CS1 maint: Multiple names: authors list (link)
• Beidel, D. C., & Turner, S. M. (2007). Shy children, phobic adults: Nature and treatment of social anxiety disorders (2nd ed.) (pp. 11–46). Washington, DC US: American Psychological Association. doi:10.1037/11533-001
• Berent, Jonathan, with Amy Lemley (1993). Beyond Shyness: How to Conquer Social Anxieties. New York: Simon & Schuster. ISBN 0-671-74137-3.
• Bruch M. A. (1989). "Familial and developmental antecedents of social phobia: Issues and findings". Clinical Psychology Review 9: 37–47. doi:10.1016/0272-7358(89)90045-7. 
• Burns, D. D. (1999). Feeling Good: the new mood therapy (Rev. ed.). New York: Avon. ISBN 0-380-81033-6.
• Crozier, W. R., & Alden, L. E. (2001). International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness. New York: John Wiley & Sons, Ltd. ISBN 0-471-49129-2.
• Hales, R. E., & Yudofsky, S. C. (Eds.). (2003). Social phobia. In Textbook of Clinical Psychiatry (4th ed., pp. 572–580). Washington, D.C.: American Psychiatric Publishing.
• Marteinsdottir I., Svensson A., Svedberg M., Anderberg U., von Knorring L. (2007). "The role of life events in social phobia". Nordic Journal of Psychiatry 61 (3): 207–212. doi:10.1080/08039480701352546.  CS1 maint: Multiple names: authors list (link)

External links

• Social Anxiety (including self-help links) at DMOZ
• Support Group Providers for Social anxiety disorder at DMOZ

UpToDate Contents

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• 1. 社会不安障害の薬物療法 pharmacotherapy for social anxiety disorder
• 2. 社会不安障害：疫学、臨床症状、および診断 social anxiety disorder epidemiology clinical manifestations and diagnosis
• 3. 社会不安障害の心理療法 psychotherapy for social anxiety disorder
• 4. 小児における不安障害：評価および診断 anxiety disorders in children assessment and diagnosis
• 5. 小児における不安障害：疫学、病因、臨床症状、および経過 anxiety disorders in children epidemiology pathogenesis clinical manifestations and course

English Journal

• The effect of verbal and imagery-based worry versus distraction on the emotional response to a stressful in-vivo situation.

• Skodzik T1, Zettler T2, Topper M3, Blechert J4, Ehring T5.
• Journal of behavior therapy and experimental psychiatry.J Behav Ther Exp Psychiatry.2016 Sep;52:51-8. doi: 10.1016/j.jbtep.2016.03.003. Epub 2016 Mar 15.
• BACKGROUND AND OBJECTIVES: According to the Contrast Avoidance Model of worry, worrying induces prolonged negative affect and arousal and thereby suppresses sharp shifts in negative affect. The verbal and abstract nature of worry may be responsible for these effects as verbal thinking has been found
• PMID 27016629

• Vigilance-avoidance and disengagement are differentially associated with fear and avoidant behaviors in social anxiety.

• Evans TC1, Walukevich KA2, Britton JC2.
• Journal of affective disorders.J Affect Disord.2016 Jul 15;199:124-31. doi: 10.1016/j.jad.2016.04.003. Epub 2016 Apr 11.
• BACKGROUND: Individuals with Social Anxiety Disorder (SAD) often exhibit preferential attention for social threat, demonstrating abnormal orientation to threat (i.e., vigilance-avoidance) and/or difficulty disengaging from threat. However, no research has compared the relationship between attention
• PMID 27131063

• The structure and intensity of self-reported autonomic arousal symptoms across anxiety disorders and obsessive-compulsive disorder.

• Berle D1, Starcevic V2, Milicevic D3, Hannan A3, Dale E3, Skepper B3, Viswasam K4, Brakoulias V2.
• Journal of affective disorders.J Affect Disord.2016 Jul 15;199:81-6. doi: 10.1016/j.jad.2016.04.010. Epub 2016 Apr 12.
• BACKGROUND: Heightened autonomic arousal symptoms (AAS) are assumed to be a central feature of anxiety disorders. However, it is unclear whether the magnitude and profile of AAS vary across anxiety disorders and whether heightened AAS characterises obsessive-compulsive disorder (OCD).AIMS: We sought
• PMID 27093491

Japanese Journal

• 性別違和をもつ人々の実態調査 : 経済状況、人間関係、精神的問題について

• 松嶋 淑恵
• 人間科学研究 34, 185-208, 2013-03-00
• … The concept of Gender Identity Disorder has taken hold in Japan, allowing medical care and legal change of sex for people with Gender Dysphoria. … However, there is a negative understanding that assumes having a gender identity that differs from one's sex is a disorder. … Anxiety about one's transition led to inability to play the social role one wished more so than discontent with one's physical transformation. …
• NAID 120005262654

• 糖尿病患者の睡眠障害について(<特集>内分泌・代謝疾患の心身医療)

• 清水 夏恵,村松 芳幸,成田 一衛
• 心身医学 53(1), 29-35, 2013-01-01
• 糖尿病患者では高血糖や神経障害などが不眠を認める原因と考えられており,一方で睡眠時間の低下や質の低下が糖尿病を引き起こす可能性も指摘され,相互に影響を及ぼしあっていると考えられている.また睡眠時無呼吸症候群や,抑うつや不安など精神症状を合併しやすいため睡眠障害をきたしやすいとも指摘されている.糖尿病患者の多くは矢感情症,失体感症の存在が明らかであることも指摘されており,不眠を自覚せず訴えがないため …
• NAID 110009578490

• 社交不安障害における認知行動モデルとHPA系 (特集 不安・うつの行動科学)

• 城月 健太郎
• 精神科 21(5), 574-577, 2012-11-00
• NAID 40019482566

Related Links

• Social Anxiety Disorder

Social anxiety disorder, also called social phobia, is an anxiety disorder in which a person has an excessive and unreasonable fear of social situations. Anxiety (intense nervousness) and self-consciousness arise from a fear of being closely watched, judged, and criticized by others. A person ...

• Social Anxiety Disorder and Social Phobia Support

Support for those who suffer from Social Anxiety Disorder (Social Phobia): causes, symptoms, treatments, groups, forums and chat. ... Our community is a welcoming place for people with social phobia to communicate with each ...

Related Pictures

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★リンクテーブル★

リンク元	「社会恐怖症」「SAD」
関連記事	「disorder」「anxiety」「social」

「社会恐怖症」

　　[★]

英

social phobia, social phobia

同

(アメリカ精神医学会)社会不安障害, social anxiety disorder, SAD

関

社会恐怖。(ICD-10 F40)恐怖症性不安障害、神経症性障害

ICD-10

• F40.1 Social phobias

疫学

• 生涯有病率 0.36-10.8%
• 女性が男性の2倍以上らしい
• 20歳代後半で好発

臨床的特徴

• 羞恥恐怖性
• 状況依存性
• 不安喚起性
• 身体表出性
• 性格起因性
• 現実回避性

参考

• 1. 社会恐怖 - wiki ja

• http://ja.wikipedia.org/wiki/%E7%A4%BE%E4%BC%9A%E6%81%90%E6%80%96

国試

• 105F004：「人前では緊張して思うように話ができない」
• 101G003
• 100D021：10歳ころから、人前で食事をしたり、話をしたりするのが極端に苦手になった。就職してからは、周囲から見られているようで、電車での通勤が辛かったと言う。

「SAD」

　　[★]

• 社会不安障害 social anxiety disorder
• 分離不安障害 separation anxiety disorder

「disorder」

　　[★]

• 障害：個人的苦痛や機能の障害があるので「疾病」とは言えるものの、その背景にある臓器障害がもう一つはっきりしない場合に用いられる。(PSY.9)

• n.

• an untidy state; a lack of order or organization (⇔order)
• violent behaviour of large groups of people
• an illness that cause a part of the body to stop functioning correctly

• 注意

disease <> illness <> disorder

• vt.

• 乱す、乱雑にする。(人)の(心身の)調子を狂わせる。

• vi.

　 　 　 　

「anxiety」

　　[★]

• n.

• 心配、不安、懸念
• 悩みの種、心配事
• 望み、切望、渇望
• (医)不安神経症

　 　 　

「social」

　　[★]

• adj.

• 社会的な、社会性の

関

sociality、socially