Review of a DSM-V Diagnosis: Social Anxiety Disorder

Review of a DSM-V Diagnosis: Social Anxiety Disorder

Social Anxiety Disorder which is also known as Social Phobia was first introduced in the DSM and modifications on the diagnostic criteria, prevalence and other disorder-related descriptions have been made in the DSM-5(Hofmann & Otto, 2017). Having the fifth edition published and being widely used around the world, it is necessary to analyse and evaluate the extent and the application of the latest DSM in identifying, assessing and treating Social Anxiety Disorder with up-to-date empirical literatures and research.

Diagnostic criteria and Typical Presentation

According to the ten diagnostic criteria listed in DSM-V(American Psychiatric Association, 2013), an individual should have these features when he/she is diagnosed to have social anxiety disorder. Pronounced fear or anxiety is recognised in social situations in which scrutiny may happen on an him/her(Hofmann & Otto, 2017). Fear or anxiety must be found among children when interacting with both peers and adults(American Psychiatric Association, 2013). Thus, individual is usually noticed to have difficulties in talking to others, keeping and maintaining relationships, presenting and performing in public, work, school or other social setting(Solomon, Leichsenring, & Leweke, 2017). The individual considers his/her anxious behaviour and showing anxiety symptoms such as uneasiness and inflexible body movement, avoiding eye contact and overly soft-spoken tone are boring, undesirable, unfavourable or weak(Moscovitch et al., 2013). He/she fears that such behaviours and reactions may be negatively judged or evaluated by others in social situations and may result in giving offending impression or being rejected or humiliated(Teale Sapach, Carleton, Mulvogue, Weeks, & Heimberg, 2014). The fear or anxiety can regularly triggered when an individual is being exposed to social situations and may result in severity varied signs of anxiousness (American Psychiatric Association, 2013). Signs of anxiousness such as severe blushing, uncontrollable tremor, sweating and sense of nauseous can be noticed in individual when exposing around people, while children tend to express their fear or anxiety through crying, speech and body freezing or trembling, and behavioural outburst like emotional tantrums(Moscovitch et al., 2013). Though, overestimation of negative outcomes is commonly found among individuals, the fear or anxiety about the social situations and social context are perceived to be unrealistic and the actual/potential risks may be exaggerated(American Psychiatric Association, 2013). Individual may therefore have a tendency to avoid or tolerate with social situation and the possible fear or anxiety caused by foreseeable and unexpected situations and excessively nervous and worried about the situations days or weeks beforehand(Solomon et al., 2017). A diagnostic threshold has been established in the DSM to give a clear guideline for counsellor to differentiate social anxiety disorder from other disorders. The fear or anxiety and related behaviours are continuously reported or observed for at least six months, and has significantly impaired individual’s everyday life including wellbeing, professional, social and other functional aspects such as unemployment, social impairment and decrease in productivity, and caused serious distress(Aderka et al., 2012; American Psychiatric Association, 2013). An individual who has the mentioned characteristics is speculated to have social phobia, however his/her usage of other substances, pre-existing medical condition, other possible mental disorder must be considered or eliminated to make a precise assumption for example, the drug or substance abuse, panic disorder, Parkinson’s disease and parental medical backgrounds(American Psychiatric Association, 2013).

Prevalence

Social anxiety disorder is one of the mental disorders that commonly found in across countries including the United States, Australia and Canada (Crome et al., 2015; Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012; Mackenzie & Fowler, 2013; Solomon et al., 2017). Social anxiety disorder annually distresses approximately 7-8% of the population and has a lifetime prevalence of 12-13% among adults, children and adolescents in United States (Kessler et al., 2012; Ruscio et al., 2008; Solomon et al., 2017). Note that prevalence for less than twelfth months period cluttered around 0.5%-2%(American Psychiatric Association, 2013). It averagely starts developing among adolescence at the age of thirteen and usually associated with the stressful or embarrassing experiences they had, severity of the disorder is differed regarding to the age, gender, socioeconomic background and culture of an individual(Hofmann, Anu Asnaani, & Hinton, 2010; Kessler et al., 2012; Ruscio et al., 2008). Both 12-month and lifetime prevalence varies in which young adults have a higher estimation and will drop by aging; women are more likely to have this disorder when comparing to men across different age groups and cultures; rate in European countries are significantly greater than non-European countries, and individuals with lower socioeconomic status has a higher prevalence rate in contrast to those in higher socioeconomic status (American Psychiatric Association, 2013; Hofmann et al., 2010; Kessler et al., 2012; Muntaner, Eaton, Diala, Kessler, & Sorlie, 1998; Prins, Bates, Keyes, & Muntaner, 2015; Ruscio et al., 2008; Wang et al., 2014).

Impact of Diagnosis/Disorder

Social anxiety disorder is correlated to an increase in school dropout rate, unemployment, and decrease in quality of life, However, it was suggested that sense of humiliation, and possible stereotype and discrimination may associate with being labelled as mentally ill(Gondek, Kotowicz, & Kiejna, 2017). Individual may be more fearful about both positive and negative evaluation of him/herself and others and have more avoidant or withdrawal behaviours. For example, he/she may find the positive support from friends and family extremely stressful as the people and the social situations are what trigger the disorder and the possible expectations from others may also worsen the condition; he/she may have a more negative self- view and possible judgements due to the labelling could affect both how individual perceive him/herself and how individual thinks people evaluate him/her. Also, DSM-V suggests that it is the counsellor’s role to assess and define individual’s degree of excessive anxiety or fear, the judgement may be more rational and objective as counsellor will normally use scales and tests in the diagnosing process rather than relying on the individual’s awareness and perception.

Assessment

Assessment is necessary because some features of social anxiety disorder such as avoiding social situations and panic attacks are shared in agoraphobia, panic disorder and generalised anxiety disorder(American Psychiatric Association, 2013). Brief screening is recommended before conducting a comprehensive assessment to examine the severity of individual’s condition (Pilling et al., 2013). Two-item generalised anxiety disorder scale (GAD-2) and mini-social phobia inventory(Mini-SPIN) are found to be significant in briefly predicting social anxiety disorder among adults (Osório, Crippa, & Loureiro, 2010; Plummer, Manea, Trepel, & McMillan, 2016). However, children and adults are differed in cognitive development and anxious or fearful expressions, adjustment in assessing for social anxiety disorder. Similar scales can be used in screening but the presentation of the items should be different for example by using storytelling techniques which can enhance children’s cognitive understanding of the context(Adrián, Clemente, & Villanueva, 2007). Scenarios about social anxiety disorder such as people getting fearful in doing things with others who they are unfamiliar with, people being very worried about doing things when they are being watched and think others will make fun of them, etc. are presented to illustrate the key cognitive, interactional and behavioural features of social anxiety disorder in a more easily comprehended way, several questions including in the scale are rephrased and asked based on the children’s context such as whether they have the same experiences as the person in scenarios when talking, eating, at school, taking part in dramas and  reading aloud in class (Pilling et al., 2013).

Both scales try to identify the level of anxiety by asking individual about his/her frequency or the extent of anxious thoughts. If an individual scores six or higher in Mini-SPIN/ scores three or more in GAD-2 on the screening process, a more comprehensive assessment is needed(Donker, van Straten, Marks, & Cuijpers, 2011).Although both tools are effective in predicting social phobic condition, GAD-2 is only a general indicator for wide-range of anxiety disorders such as social anxiety and panic disorder by asking how often does an individual feel anxious and uncontrollably worried (Donker et al., 2011; Plummer et al., 2016). It was thereby suggested that two further screening questions on individual’s condition should be asked to check if he/she has the tendency of avoiding social situations and interaction, and if the feelings of anxiousness and embarrassment are particularly triggered in social situations(Pilling et al., 2013). GAD-2 was found to be sensitive in detecting anxiety but not adequate to identify generalised anxiety disorder (Delgadillo et al., 2012; Plummer et al., 2016). These results demonstrate that GAD-2 is appropriate tool in screening as to get a brief idea about the severity of the condition as GAD-2 is not precise as GAD-7 in distinguishing generalised anxiety disorder but still appropriate in differentiate the anxiety level, the items used in GAD-2 are common features find among anxiety disorders such as social anxiety disorder and panic disorder (Delgadillo et al., 2012). Systematic review in application of GAD-2 conducted by Plummer et al. (2016) found similar result that GAD-2 was appropriate in assessing the anxiety level but not accurate in diagnosing the type of anxiety disorders. Although the studies have potential problems of subjectivity and publication bias in which the researcher might be selective in reporting and ignore the insignificant data that failed to differentiate the anxiety level.

Mini-SPIN on the other hand is specifically focused on social anxiety disorder and has an 88% of sensitivity which demonstrated a high accuracy in diagnosing social anxiety disorder, and an estimated specificity of 90% which suggested a high accurateness in differentiating non-social anxiety disorders (K. Connor, Kobak, Churchill, Katzelnick, & Davidson, 2001; K. M. Connor et al., 1999). Although study conducted an online Mini-SPIN by Fogliati et al. (2016) found that the scale has a strong ability of 86% sensibility in accurately identifying social anxiety disorder, unlike the face-to-face assessment,  a rather low specificity rate of 64% was found in the online version of Mini-SPIN suggested possible overestimation of social anxiety disorder. The findings are in line across time suggesting that the scale is reliable in positively diagnose the disorder. Mini-SPIN is generalizable across cultures and can be done either face-to face or online although the cut-off points in different countries varied in which the possibility for individual to be diagnosed with social anxiety is between six and seven (K. Connor et al., 2001; El Rey & Matos, 2009; Fogliati et al., 2016; Wiltink et al., 2017).

Further assessments are performed to get a more comprehensive view of individual’s condition. This can be done by discussing his/her current anxiety and perceived potential threats when engaging in social situations, associated behaviours and thoughts, alcohol or drug used, relationships with others etc., or by performing more detailed self-report assessment such as the Liebowitz Social Anxiety Scale (LSAS) and Social Interaction Anxiety Scale (SIAS) (Mattick & Clarke, 1998; Pilling et al., 2013; Rytwinski et al., 2009). Self-report version of LSAS (LSAS-SR) is a measurement with twenty-four items assessing the dimensional severity and the treatment progress of social anxiety disorder(Oakman, Van Ameringen, Mancini, & Farvolden, 2003). The scale contains eleven items regarding to the social interactions and thirteen items on individual’s performance in public rating from 0 to 3 in terms of the severity and the frequency of fear and avoidance(Rytwinski et al., 2009). SIAS is a twenty items scale designed to assess general interactional fear in social situation such as his/her emotional response when engaging in social situations, the nervousness about others’ opinions and fear of being scrutinized by others rating from 0 to 4 regarding to the tendency of reflecting him/her appropriately(Brown et al., 1997).

Several adjustments and validations have been established to identify the severity among age-varied audience in which LSAS-CA-SR is a justified version for assessing social anxiety condition in children and adolescents whereas LSAS-SR is an adjusted self-reporting version for adults(Oakman et al., 2003; Shachar, Aderka, & Gilboa-Schechtman, 2014).  Items in LSAS-CA-SR were slightly adjusted to fit into relevant education and social context for example, LSAS-SR measures the fear and avoidance when using telephone in public whereas LSAS-CA-SR measures the same aspect by rephrasing the original statement to talking on the phone with classmates or others(Dos Santos, Loureiro, Crippa, & De Lima Osório, 2013; Shachar et al., 2014). Recent study on the cut-off point for LSAS-CA-SR and LSAS-SR in which Social anxiety disorder is unlikely are thirty and thirty-five respectively (von Glischinski et al., 2018). These results supported the findings of Rytwinski et al. (2009) in which scored below thirty suggesting that disorder is unlikely, and the higher the score the more likely an individual to have social anxiety disorder. Although LSAS was found to be a strong predictor for social anxiety disorder in Brazil and Germany as well as a good indicator of treatment progress, a large measurement error was found in Japanese population in which LSAS was unable to detect individual changes in precise (Loureiro, 2013; Takada, Takahashi, & Hirao, 2018; von Glischinski et al., 2018) Possible differences between Western and Asian cultures.

Thus, it is the counsellor’s judgement in deciding which assessment instruments and how should the tools be used. Although all instruments are suggested to be effective, if the counsellor is uncertain about his/her hypothesis, using the Mini-SPIN might eliminate the other potential disorder in explaining the client’s condition. On the other hand, using a specific predictor like the Mini-SPIN helps counsellor in eliminating hypotheses if the client gets a score lower than six in Mini-SPIN or a score lower than three in GAD-2. Also, both measurements are over simplified in assessing the disorder, if the counsellor completely reply on the two tools in diagnosing, the judgement will not be precise and over diagnosis may happen. These indicators can only predict the risk of the disorder and further assessments must be carried out. Comparing to the screening assessments, LSAS is a reliable and valid assessment and a progress tracking tool. Although all predictors take the differences in cognitive understanding across ages into account. LSAS is better in predicting the severity and a more holistic view of individual’s fear and anxiety in social performance and interactions, and is generalisable in terms of age and culture though counsellor should be aware of cultural background of the client. Aderka et al. (2013) found cutting score for the measurements overestimated the prevalence of social anxiety disorder in Australia for 15% to 27%, suggesting that people may have the potential risk of being over-diagnosed if the assessment is not appropriately carry out by counsellor, thus being alert to margin scorer in preventing clinical condition and avoiding over-dependent on the tools are necessary for a counsellor to reduce over/under-diagnosis.

Treatment

As social anxiety disorder can cause severe impairing in personal relationships, educational and work functioning, treatments are needed such as the cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT). CBT is the most common therapy which emphasises on changing how individual thinks and behave in fearful situation (Hofmann & Otto, 2017). A typical CBT treatment plan involves twelve to sixteen sessions of sixty to ninety minutes each, and improvement will only be noticeable after six to twelve weeks(Narr & Teachman, 2017). Both psychoeducation and preventing strategies are both involved in CBT. It is suggested by the National Institute for Health and Care Excellence (NICE) that it is vital to help individual in understanding the nature about the disorder and how it impact his/her thoughts, feelings and behaviours before introducing interventions into the treatment(Pilling et al., 2013). Interventions include cognitive restructure in which counsellor and the client will collaboratively evaluate the core beliefs and explore ways to shift self-critical, unhealthy thinking patterns and exposing method in which the counsellor will gradually expose client to different situational exercise to reduce behavioural avoidance or other safety behaviours (Hofmann & Otto, 2017). These techniques allow individual to empower his/her ability to tolerate with possible high-risk situations in the future(Pilling et al., 2013). Although counsellor should be cautious when handling the evaluation and exposure regarding to the social anxiety as it may cause more disturbances if he/she finds the experiences or confrontations are too threatening(Leichsenring et al., 2013). Another possible criticism about CBT is the reliability and generalisability of the treatment as counsellor may embed his/her cultural view of normality about the disorder when collaborating with the client in reconstruction(Woody, Miao, & Kellman-Mcfarlane, 2015). Thus, Counsellor should take cultural aspect when conducting CBT, the thought and behaviour of social anxious found in Asian community might be related to the cultural background instead of the disorder. On the onther hand,  CBT was still found to be widely generalisable as a randomised control study found that the effecacies of group CBT and internet-based CBT are similar(Hedman et al., 2011). Leichsenring et al. (2013)further confirm with a 27% higher remission rate when comparing to the waiting-list group, supported the efficiency and effectiveness of CBT in treating social anxiety disorder in Sweden and Germany.

Despite the intervention of CBT, ACT is also considered to be useful as it aims helping individual to objectively recognise and accept unpleasant experiences and enhance his/her psychological flexibility in embracing the experiences using learnt skills in order to achieve personal goals and values in life(Dalrymple & Herbert, 2007). Unlike CBT in which counsellor assists client in altering the content and frequency of fearful or anxious thoughts and feelings, ACT does not treat the anxiety symptoms but to minimise the possible functional impairments and distress resulting from the disorder by promoting internal functioning such as mindfulness and mental flexibility(Herbert & Cardaciotto, 2005). Comparison on LSAS measures between pre-treatment, mid and post-treatment found that ACT significantly improved the avoidance behaviour and quality of life (Dalrymple & Herbert, 2007) suggested that social anxiety disorder can be treated by enhance the individual’s ability in embracing his/her thoughts and feeling, and engaging to a  more meaningful behaviour.People may have difference perspectives on the definition of social normality and different mental representation or expression of social anxiety disorder for example Asian culture tend to be more emotional restraint and socially introvert than Western culture(Woody et al., 2015). ACT takes individuality into account in which possible issues regarding to the subjectivity about favourable feelings or thoughts and cultural differences can be minimised, thus the usefulness does not limit by socioeconomic and cultural aspects (Hayes, Pistorello, & Levin, 2012; Hofmann & Otto, 2017). Although there are evidence on how ACT can be applied on poor or minority context, not much evidence on ACT significantly treated these specific groups with social anxiety disorder other than the physically disabled group (Lundgren, Dahl, Melin, & Kies, 2006; Zahra Ostadian & Malihe Fadie, 2017).

Empirical literature reviews examined the efficacy of psychological interventions for social anxiety disorder such as CBT and social skills training which was the key feature in ACT and found that CBT was best suitable and effacious and estblished a strong reliability in treating the disorder(Acarturk, Cuijpers, van Straten, & de Graaf, 2009; Ponniah & Hollon, 2008). Study particularly investigated on the effectiveness of CBT and ACT, result shown that both treatments were able to reduce negative cognition equally and significantly although there were differences in speed in which negative cognition reduced more quickly in the beginning of ACT while CBT gradually reduced negative cognition throughout the treatment (Niles et al., 2014). This suggested the structuring and mechanism of the therapies are varied in which cognitive defusion approach and behavioural exposure approach work differently, yet there is no one psychotherapy that is better off. Although there is argument about third wave therapy such as the ACT is more efficious in treating mental disorder comparing to tradiotional first and second wave therapies such as behavioural therapy and CBT in which third wave therapy aims to change the meaning or the view to the individual using a more holistic approach (Hayes et al., 2012). It is the cousllor’s role to discuss with the client and apply the most suitable form of psychotherapy that works ont the client.

To conclude, DSM-V explains the features, potential impacts for social anxiety disorder. It can be used to differentiated from other disorders and determined the severity by scales like SPIN and LSAS suggesting that the scales have strong specificity and sensitivity based on the criteria and features mentioned in DSM-V although it may be argued that DSM-V may have generalisability issue when applying to population of different culture such as Asians. Treatments such as ACT and CBT are developed and tested in terms of their effectiveness. Although there are evidence suggesting that CBT is better and commonly used in treating social anxiety disorder, ACT has the equivalent ability in treating the symptoms. This suggests that providing the most appropriate therapy to individual is more important than providing the best therapy as one therapy may work on an individual but not on everyone, and it is the collaboration between counsellor and client to decide which therapeutic treatments suit him/her most.

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