The prevalence of social phobia: a review

Prevalence of social phobia: A review

Nursu CAKIN MEMİK, Ozlem YILDIZ, Umit TURAL*, Belma AĞAOĞLU

Kocaeli University Faculty of Medicine, Child and Adolescent Psychiatry Department, Kocaeli, Turkey

*Kocaeli University Faculty of Medicine, Department of Psychiatry, Kocaeli, Turkey

Summary:

Objective: Social phobia has been an important public health problem in recent years. is accepted as The aim of this article is to draw attention to social fears and social phobia and to discuss its prevalence, since the diagnosis and treatment of social phobia is less than expected despite its prevalence.

Method: Studies on the prevalence of social phobia in the last ten years (1999-2009) search engines pubmed and medline centrale “social phobia”, “social anxiety disorder”, “epidemiology”, “prevalence” “children It was searched and reviewed using the keywords “” and “adolescent”.

Results: Twenty-two published research papers on the prevalence of social phobia over a ten-year period were evaluated. When these studies are examined, the prevalence of the population differs significantly between countries, with lifetime prevalence rates varying between 0.4% and 13.7%, and twelve-month prevalence rates varying between 1.3% and 7.9%. It was found to vary between 1.6% and 0.4%-17% for those aged 18 years and above. When classified by gender, prevalence rates were found to be higher in women than in men.

Discussion: The significant difference in the prevalence of social phobia between cultures was an important finding. This difference may be due to the pattern difference between the studies, and it also suggests that the diagnostic criteria for social phobia may not be valid in all cultures. In addition, it was thought that the difference in the measurement tools, the time period in which the prevalence was measured and the age groups were different in each study may have led to this result.

Conclusion: Social phobia, which is known to be an important public health problem, is common. It is obvious that studies to be carried out in the field of social phobia should be increased because it causes social, occupational and economic problems at the individual and societal level.

Key words: epidemiology, prevalence, social phobia, social anxiety disorder

INTRODUCTION:

Social fears are normal emotions that people experience in order to adapt to social situations (1). On the other hand, social phobia is the feeling of embarrassment and intense fear of being negatively evaluated by others in social environments, and the behavior of escaping and avoiding such environments (2). Social phobia is a disorder with high economic costs, as it leads to academic failure, economic dependence, decrease in work efficiency, social inadequacy, and decrease in quality of life (3). In addition, it greatly affects family and peer relationships, which form the basic structure of daily life (4). Social phobia, which increases susceptibility to mood and anxiety disorders, increases the likelihood of comorbidity with disorders such as depression and alcohol addiction (3,5). It has been reported that social phobia is the most common mental disorder after depression, substance abuse, and specific phobia, and its lifetime prevalence varies between 0.4% and 13.7% in different studies (6-18). The high prevalence of social phobia in epidemiological samples, but low in treatment studies suggests that patients do not seek help for treatment, and that the diagnosis of social phobia is inadequate in clinical practice (19-22). In this article, it is aimed to draw the necessary attention to social phobia, which is now seen as an important public health problem, to discuss the results of published studies on the prevalence of social phobia and how these results are affected by the diagnosis system used, the time period, age group, gender and culture.

METHOD:

Studies on the prevalence of social phobia in the last ten years were evaluated using pubmed and medline centrale search engines. Studies published between 9.1999 and 9.2009 were evaluated. Screening was conducted using the terms “social phobia”, “social anxiety disorder”, “epidemiology”, “prevalence”, “child” and “adolescent”. There was no restriction on the age group in which the study was conducted. In this study, only the results of population-based studies are discussed. Studies investigating the prevalence of social phobia in samples of individuals with mental or physical illness were not included in the evaluation.

RESULTS:

The results of 22 community-based studies published in the last ten years on the prevalence of social phobia were evaluated and the prevalence rates were found to vary between 0.4% and 12.1%. When Table 1 is examined, it is seen that the average age varies between 14.4 and 39.3 years.

Measurement tool, interview style and social phobia:

When the prevalence studies on social phobia are reviewed, it is seen that CIDI (International Compound Diagnostic Interview) is frequently used as an assessment tool. In many studies, measurement tools were thought to be inadequate and it was observed that some items were added or removed or new questionnaires were created by the researchers (6,11). Pelissolo et al. created a 16-item scale from the social phobia section of the M-CIDI (Munich-CIDI) to evaluate the prevalence of social phobia (12). Again, Stein et al. carried out their studies by adding 12 questions to CIDI (6). Faravelli et al., on the other hand, added 6 questions to the MINI (Mini International Neuropsychiatric Interview) and applied the scale to the sample they determined (11). Stein et al. found that the prevalence of social phobia was 6.8% with CIDI and 7.2% when additional questions were added to CIDI to evaluate social phobia (6). As seen in Table 1, 13 of the evaluated studies used CIDI, 3 of them M-CIDI, 1 of them used the measurement tool created by adding 12 questions to CIDI, 1 of them used CIDI and SCID (DSM Axis Disorders). Structured Clinical Interview for Diagnosis), 1 used SADS (Schedule for Affective Disorders and Schizophrenia), 1 used UM-CIDI (University of Michigan-CIDI) and DIS (Composite Interview for International Diagnosis), and 1 it is seen that the study also used the FPI (Florence Psychiatric Interview) together with the measurement tool created by adding 6 questions to the MINI (6-18,23-31). Of the 22 studies included in the study, it was determined that the evaluation was made by face-to-face interviews in 18 studies, by telephone in 2, both face-to-face and telephone in 1 study, and by reaching the sample via mail in 1 study (6-18,23-31)

Diagnostic system and social phobia:

DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) is frequently used among the diagnostic classification systems. Of the 22 studies included in the study, 13 had DSM-IV, 1 had ICD-10 (International Statistical Classification of Diseases and Health Problems, Tenth Revision), 4 had DSM-III-R, 1 had ICD-10. and DSM-IV, 1 study used ICD-10 and DSM-III-R, and 1 study used DSM-III and DSM-III-R together (6-18,23- 31). In a study conducted, according to DSM-III-R diagnostic criteria, the prevalence of social phobia at one month, one year, and lifetime was 7.9%, 9.0% and 11.7%, respectively, but according to ICD-10, these rates were % respectively. It was found that it decreased to 4.7-5.2% and 6.7% (15). In another study, while the one-year prevalence of social phobia was 1.3% according to DSM-IV criteria, this rate nearly doubled and increased to 2.7% according to ICD-10 (23).

Age and social phobia:

When evaluated according to age, it is seen that the prevalence rates vary between 1.6% under the age of 18, and between 0.4% and 17% in studies conducted with individuals aged 18 and over.

Essau et al., in their study with adolescents aged 12-17, found that the prevalence of social phobia increased with age, with the highest increase occurring between the ages of 12-13 and 14-15 (8). In the study of Faravelli et al., it was reported that the mean age at which social phobia symptoms first started was 15.5±12.6, and the mean age of being diagnosed with social phobia was 28.8±11.5 (9). In another study, the median age of onset of social phobia was found to be 7 (6). In the study of Grant et al., the mean age of onset of social phobia was found to be 15.1 and in the study of Lee et al. it was found to be 18.0 (10.27).

Gender and social phobia:

When classified by gender, the prevalence rates vary between 1.3-17.2% in females and 0.4-10.0% in males. Consistent with each other, in all the studies we evaluated, it was shown that social phobia is more common in women than in men.

Subtypes of social phobia:

Stein et al. reported that 26.8% of their patients diagnosed with social phobia were diagnosed with generalized social phobia, and the remaining 73.2% with uncommon social phobia. (17). In another study, the prevalence of common social phobia was 7%, and the prevalence of uncommon social phobia was 17% (30). In the study of Pelissolo et al., it was found that the prevalence of social phobia varied between 1.9% and 0.9% when the diagnostic criteria for social phobia were considered limited and narrow, and between 7.3% and 2.3% when the diagnostic criteria for social phobia were relaxed (14). ). Although the lifetime prevalence of social phobia was found to be 3.27% in the study of Faravelli et al., the rate decreased to 3.09% when the social phobia diagnostic criteria were narrowly evaluated (9).

Culture and social phobia:

When comparing cross-continental studies, lifetime prevalence rates are between 1.6% and 17% in Europe, 5% and 12.1% in the USA, and Asia. It is seen that it is between 0.4% and 0.82%, 10.2% and 11.7% in South America, and the one-year prevalence varies between 1.3% and 2.7% in Australia.

Time period and social phobia:

When Table 1 is examined, it is seen that the prevalence rates are different from each other in lifetime, twelve months, six months and one month. It is observed that the lifetime prevalence rates vary between 0.4% and 13.7%, and the twelve-month prevalence rates vary between 1.3% and 7.9%. In a study by Rocha et al., according to DSM-III-R diagnostic criteria, the prevalence of social phobia at one month, one year, and lifetime was 7.9%, 9.0% and 11.7%, respectively, and according to ICD-10, respectively. It was found to be 4.7%-5.2% and 6.7%, and it was revealed that there was a significant difference in the results according to the time period in which the evaluation was made (15).

DISCUSSION:

Measurement tool, interview style and social phobia:

Considering the evaluated studies, different measurement tools were used and items were added or removed from the measurement tools in order to better measure social phobia. Some items appear to have been changed. It is clear that this diversity in measurement tools also affects the results of the study and the prevalence rates of social phobia. As in the different studies we reviewed, Zimmerman and Mattia’s study also found that the prevalence rates changed with the change of measurement and diagnostic tool, even in the same sample group, and the rate of social phobia with semi-structured interview was 9 times higher than with unstructured clinical interviews (28.6%, respectively). , 3.2%) (22). When we look at the studies included in the research, it is seen that the way of application of measurement tools (phone call, mail, face-to-face interview) also differs. It is clear that evaluation methods limit the study in studies where measurement tools are applied by telephone or mail. If the prevalence of social phobia, which has emerged as a result of a research, is to be evaluated, it is obvious that it is important to know the measurement tool used and the method applied for the measurement.

Diagnostic system and social phobia:

It is clear that the use of different diagnostic classification systems will affect prevalence results in studies. It was observed that the DSM-IV diagnostic classification system was used in most of the studies we evaluated. In a study by Canals et al., while the prevalence of simple/social phobia was 1.7% according to DSM-III-R criteria, this rate increased to 5.5% according to ICD-10 (32). Again, in the study of Wacker et al., while the one-year prevalence of social phobia was 16% according to DSM-IV criteria, this rate decreased to 9.6% according to ICD-10 (33). Studies on the prevalence of social phobia show that small changes in diagnostic criteria lead to large changes in prevalence rates (34,35). In the study conducted by Fehm et al., 2% of those who fully met the DSM-IV diagnostic criteria for social phobia, 3% of those who were diagnosed with subthreshold social phobia who had a single criterion missing from the DSM-IV diagnostic criteria for social phobia, 3% or two or more of the DSM-IV diagnostic criteria for social phobia. also stated that individuals with symptom-level social anxiety who did not meet more criteria had a prevalence of 7.5% (24). It is seen that it is important to know the criteria included in the diagnosis of social phobia along with the diagnostic classification system used in the evaluation of prevalence rates.

Age and social phobia:

The prevalence of social phobia in adolescence is 0.5%-4% (8.36) in community-based studies, and 3%-6.8% in the sample of primary care patients. (37.38) has been reported to vary between As a result of studies conducted in Germany and the USA, it was determined that the lifetime prevalence of social phobia in adolescents can vary between 5% and 15% (39,40).

In a study conducted with pediatricians in primary care, it was found that social phobia, especially the common type, is the most common anxiety disorder after specific phobia in children and adolescents (37). Despite this, it has been observed that pediatricians rarely diagnose social phobia and patients cannot receive treatment for social phobia (37). This finding shows us that although it is a very common problem in childhood, social phobia is not recognized by physicians. It has been reported that the age of onset of social phobia may be as early as 5 years old (as cited in 41). It is quite late for the cases to apply for treatment. Generally, those with social phobia apply for treatment 10 years after the symptoms appear (42). Social phobia causes failure in many areas of people’s lives such as school, work, social life, and relations with the opposite sex. In a study conducted, it was found that only 23.5% of social phobics sought treatment because of their problems, despite such negative results (8). Although the researchers agree that social phobia is a disorder that should be recognized and treated early because it causes serious economic losses both in the individual and social areas, it is surprising that the number of studies conducted in childhood and adolescence is low. Difficulties experienced due to social phobia cause patients to change their lifestyles and decrease their quality of life. Considering all these negativities that social phobia causes in the individual, it is thought that prevalence studies to be carried out in children and adolescence will reduce the early recognition and disability of patients who apply to treatment quite late.

Gender and social phobia:

Considering the prevalence between genders in community studies, it is clearly seen that social phobia is more common in women than in men. On the other hand, it is known that seeking treatment is higher in males, and therefore, in prevalence studies conducted in clinical samples, the prevalence of social phobia is higher in males (43). This can be explained by the fact that the severity of the destruction and inadequacy caused by social phobia in the social roles of men is more and more noticeable. The fact that men have social roles in society, such as providing for a house and earning money, may cause them to be in more social environments and cause the prevalence of social phobia in the clinical sample to be higher in men. The fact that the prevalence of social phobia in women is lower in clinical samples than in community samples may be due to the fact that women undertake tasks such as housework and childcare and enter less social environments than men. On the other hand, shyness and shyness are attributed to the female gender and reinforced with positive feedback. For this reason, women are pleased with the feelings of shyness and shyness, which are important features of social phobia, and they may not complain about these features. However, since these feelings counted in men are perceived as a deficiency and negative feature by the society, it can be said that men become more aware of the problem.

Social phobia subtypes:

Social phobia diagnostic criteria were included in the DSM-III for the first time (44). According to DSM-IV, if fear and/or avoidance covers most social situations, it should be mentioned as general social phobia (2). Fear and/or avoidance are found in only one or two areas in uncommon social phobia or in limited areas compared to common social phobia (45,46). The majority of social phobics who apply to a physician and seek help are those with generalized social phobia (47-50). Compared to uncommon social phobia, it has been reported that common social phobia starts at an earlier age, has a higher comorbidity rate, higher level of dysfunction, lower quality of life, higher substance use rates, and a worse prognosis (3,47,51).

Knowing the subtypes of social phobia is important because it may affect the etiological difference and treatment response (52-54). This distinction, which should be made in the diagnosis and follow-up phase, is a situation that will affect the selection of the treatment method and the scientific researches to be made in this field.

Culture and social phobia:

Among the studies we evaluated, it was determined that 6 studies were conducted in the Americas, 8 in Europe, 2 in Australia, and 3 in Asia and South America. When the prevalence studies of the last ten years are reviewed, it is seen that the most research on this subject has been done in the European continent. When the prevalence rates are evaluated, it is remarkable that the prevalence rates of social phobia are at the highest level in Europe, while these rates are low in the Asian continent. It is thought that the prevalence of social phobia may change in various societies as a result of the society’s individual characteristics as in America or social characteristics as in Asia, or as the climate and geographical structure affect the population density in different ways, as well as the socialization of individuals (55). Many previous studies have shown that the prevalence of social phobia in eastern countries is lower than in western countries (28,33,56-64). The fact that people in the eastern regions have a social rather than individual commitment may be related to this surprising finding, which is likely to be caused by social effects rather than individual performance. Social phobia may be considered as a more serious medical problem in the West, or the structural characteristics of western societies may lead to more social anxiety. In addition, social phobia may be considered as a personality trait rather than a disease in eastern societies. Diagnostic criteria and measurement tools developed in the West may not be able to adequately assess or measure social phobia or social anxiety, which has a complex nature and unclear boundaries in the eastern society. This brings up the debate on how valid social phobia diagnostic criteria are in different cultures and societies. Study patterns and handling of different symptom and symptom clusters in common or uncommon social phobia may also have contributed to this difference in prevalence rates. It is known that sociocultural characteristics will lead to behavioral, intellectual and emotional changes in the person. For this reason, it is clear that cultural characteristics should be given importance in researches.

Time zone and social phobia:

It is accepted in epidemiological studies that remembering the problem for a long time may be wrong (65). Depending on the period in which the prevalence was investigated, significant differences may occur in the research results (11,14,23,33).

It is clear that the time frame examined in studies may affect the interpretation of the study. For this reason, it is thought that it is important to interpret the prevalence rates by taking into account the time period in which the evaluation was made.

Conclusion:

The common results of the 22 studies evaluated can be summarized in 3 items as follows.

Different measurement tools used to determine the prevalence of social phobia, interview style, classification system or the time period taken into consideration affect the results of prevalence studies.

It has been shown in many studies that social phobia is more common in developed countries than in developing countries.

Despite the onset of social phobia in childhood-adolescence and the fact that patients seek treatment quite late, prevalence studies were found to be scarce in this period. There is a need for studies on the prevalence of social phobia in childhood-adolescence because it is scarce. However, it is understood that social phobia is more common in the female gender.

The early onset feature of social phobia, its great impact on functionality, its prevalence and high comorbidity rates indicate the necessity of early diagnosis and treatment. In addition, the significant difference in the prevalence rates of social phobia in eastern and western countries clearly reveals the importance of intercultural studies. Giving importance to culture, measurement tool and study pattern in the planned studies will increase the quality of the information to be obtained in the field of social phobia. Studies to be carried out especially in adolescence and childhood will provide important information about the onset, prevalence and course of social phobia.

Prevalence studies on mental disorders are extremely important in order to organize community mental health interventions (55). As in other anxiety disorders, the high individual exposure and social cost in social phobia reveals the need for prevalence studies in this area (66).