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Social disorder: Much more than shyness by Margot Shields

This article is an adaptation of “ disorder—beyond shyness” in How Healthy Are Canadians?, an annual supplement to Health Reports (Statistics Canada Catalogue no. 82-003), published in October 2004. For a complete list of references, please consult the original work, available free at www.statcan.ca/english/freepub/82-003-SIE/82-003-SIE2004000.htm.

ost people have felt awkward as shyness, studies have shown it to aged 15 years or older. It also or embarrassed in a social or have a chronic and unremitting discusses the age of onset, duration M performance situation at course that is characterized by severe of symptoms, relationship with other some point in their lives. However, anxiety and impairment.2 The mental disorders, the burden of the people with social disorder has been aptly described as condition as well as the number of (also known as social phobia) “crippling shyness.”3 people with the disorder who sought experience much more discomfort It is difficult to estimate how many professional help. than this. They go through life individuals actually have social extremely uncomfortable or para- anxiety disorder, as most people with Performing or public speaking lyzed in social situations because the condition do not seek profes- most scary for those with social they intensely being scrutinized sional treatment for their . anxiety or embarrassed. So they either totally was thought According to the 2002 CCHS, just avoid social encounters, or them to be a rare and usually mild over 2 million Canadians aged 15 or with dread and endure them with condition until the 1980s, when it older (8% of the total population) intense distress.1 Although social was recognized as a separate disor- reported they had a “lifetime history” anxiety disorder is often dismissed der in the Diagnostic and Statistical of social anxiety disorder; in other Manual of Mental Disorders. Then in words, they had symptoms at some the 1990s, several epidemiological point in their lives. Approximately studies suggested that social anxiety 750,000 people (3%) currently had disorder was associated with the disorder, meaning they had significant impairment and was far symptoms in the 12 months before more prevalent than initially the survey interview. thought.4 In fact, by this time, it was The most commonly feared considered one of the most common situation for people with social mental disorders. Because few people anxiety disorder was performing or are formally treated, however, giving a talk, but many reported epidemiological population-based facing several other situations with studies are really the only way to anxiety; for example, meeting new estimate the prevalence of social people, talking to authority figures, anxiety disorder and the burden it or entering a roomful of people. The can impose. majority with social anxiety disorder Using data from the 2002 reported fearing 10 or more of the 14 Canadian Community Health Survey social situations covered by the (CCHS): Mental Health and Well- CCHS, and close to 95% feared 5 or being, this article presents current more. For half of the situations, and lifetime prevalence rates of women were slightly more likely than social anxiety disorder for Canadians men to report a fear.

22 Canadian Social Trends Summer 2005 Statistics Canada — Catalogue No. 11-008 CST What you should know about this study

The Canadian Community Health Survey (CCHS) cycle 1.2: algorithms used to identify mental disorders were revised Mental Health and Well-being was conducted in the 10 over a period of time. The questionnaire used for the CCHS provinces in 2002. The survey used the World Mental Health is available at www.statcan.ca/English/concepts/health/ version of the Composite International Diagnostic Interview cycle1.2/index.htm. (WMH-CIDI) to estimate the prevalence of various mental For some disorders, a set of screening questions was disorders in the Canadian household population aged 15 asked to determine if it would be appropriate to ask the or older. The CIDI was designed to be administered by lay respondent the more detailed questions designed to assess interviewers and is generally based on diagnostic criteria a particular disorder. This was done to reduce the number outlined in the Diagnostic and Statistical Manual of Mental of questions posed to respondents without mental disorders. Disorders, Fourth Edition. Based on the advice of experts In some cases these screening questions were also used to in the field of mental health, the WMH-CIDI and the categorize respondents as having a disorder.

Social anxiety disorder begins Social anxiety disorder is less prevalent among those early in life CST aged 55 and older A striking feature of social anxiety Lifetime Current disorder is its early age of onset: (past 12 months) symptoms typically begin appearing in childhood or early adolescence. % CCHS respondents were asked to Total 8.1 3.0 report the age at which they first Sex strongly feared or avoided social or Men 7.5* 2.6* performance situations. Among those Women 8.7 3.4 with a lifetime history of social Age group anxiety disorder, the average age of 15-24 9.4 4.7* onset was 13; only 15% reported that 25-34 9.6 3.8 symptoms first began after age 18. 35-54 9.1 3.1 By contrast, the first symptoms of 55 or older 4.9* 1.3* two other common disorders— Marital status‡ disorder and —were Married/common-law 8.0 2.5 evident much later, at ages 25 and 28, Widowed 7.0E 2.4E respectively. Divorced/separated 12.7* 5.0* Along with its early onset, social Never married 12.0* 5.0* anxiety disorder can be a long- Education‡ standing problem. Many studies have Less than secondary graduation 9.1 3.9* found that symptoms persist for Secondary graduation 8.8 3.3 years, often for two decades or Some postsecondary 10.3 3.9* longer.5 Among CCHS respondents Postsecondary graduation 8.9 2.7 with a lifetime history of the disorder, Household income the average duration of symptoms Low/lower-middle 9.8* 4.6* was 20 years. This underestimates Middle 7.8 3.0 the true burden of the disorder, Upper-middle/high 8.2 2.8 because many were still from it at the time of the survey. Note: Reference categories are marked in italics. Household population aged 15 or older, Canada excluding the territories. E Use with caution. Social anxiety disorder more common among women ‡ For people aged 25 to 64. In 2002, women were more likely than * Significantly different from estimate for reference category (p<0.05). men to have social anxiety disorder— Source: Statistics Canada, Canadian Community Health Survey: Mental Health and Well-being, 2002. both lifetime and current. The ratio

Statistics Canada — Catalogue No. 11-008 Summer 2005 Canadian Social Trends 23 previous decades is lacking. It is also Major triggers of shyness, fear and discomfort for possible that people with social CST people with social anxiety disorder anxiety disorder die at younger ages, or that the elderly may not recall Situation % who felt very shy, afraid or uncomfortable symptoms of the disorder.

92 Married people less likely to Performing/giving talk 94 suffer from social anxiety disorder Speaking up in meeting/class 87* 91 In 2002, the prevalence of social Other situation where centre of / 80* anxiety disorder was higher among something embarrassing might happen 87 people who had never married or who 81 were divorced or separated (both Meeting new people 82 5.0%) than among married individuals Taking important 79* (2.5%). Such relationships with exam/interviewing for job 84 marital status have been found in 8 69* other studies, and it is believed that Talking to people in authority 77 the early onset of social anxiety disorder hinders the development of Working while someone watches 65* 76 social skills, making marriage, or a successful marriage, less likely. Entering room when others 66* already present 73 It is also thought that failure to acquire social skills early in life Talking with people you don't 68 9 know very well 67 hampers educational success, a finding supported by the CCHS. 65 Going to parties/social gatherings 69 Individuals who had not completed their secondary or postsecondary Expressing disagreement with people 57* you don't know very well 69 education were more likely to have social anxiety disorder than were Going on date 58 postsecondary graduates. In the case 59 of postsecondary students, dropping Writing, eating or drinking while 40 out of school may relate to fears or someone watches 47 Men discomfort surrounding a new social Using public washroom 37 Women environment, such as starting 33 another school and/or living in a city away from home. Note: Estimate for each situation excludes respondents who indicated situation did not apply. Household population aged 15 or older, Canada excluding territories. Social anxiety disorder more * Significantly lower than estimate for women (p<0.05). prevalent in lower income Source: Statistics Canada, Canadian Community Health Survey: Mental Health and Well-being, 2002. households According to the 2002 CCHS, social anxiety disorder was more prevalent among individuals living in lower income households. Furthermore, of the rates of women to men was 1.2 (1.3%), a pattern also evident in other people who reported symptoms of for lifetime social anxiety disorder countries.7 The CCHS lifetime rates social anxiety disorder in the past and 1.3 for current (past 12 months). were similar among those aged 15 to 12 months were less likely to have This is consistent with other 54, after which they dropped off jobs, and those who did have jobs community and clinical studies, noticeably. It has been suggested had lower personal incomes. This which have generally found rates for that this may result from a cohort may partly result from the lower women to be higher.6 effect; that is, people born in the educational levels for people with Young people aged 15 to 24 were more distant past were less likely to social anxiety disorder, as well as more likely to have current social develop social anxiety disorder than difficulties remaining in a job that anxiety disorder (4.7%) than the more recent cohorts. It is difficult demands a fair amount of social middle-aged (3.1%), while individuals to substantiate this theory, though, interaction.10 People with social aged 55 or older were less likely because prevalence information for anxiety disorder were also more likely

24 Canadian Social Trends Summer 2005 Statistics Canada — Catalogue No. 11-008 to be financially dependent. In 2002, 10% of those who had current symp- Among those with current social anxiety disorder, toms lived in households reporting CST men were more likely than women to have had a income from social assistance or major depression welfare in the past 12 months, compared with 4% for people with no % history of the disorder. These CCHS 36* findings regarding financial depen- dence are consistent with those of Men other studies.11 28 Women Social anxiety disorder associated with other conditions Substantial evidence indicates that 14* social anxiety disorder is associated with increased risk of other anxiety, 8 mood, and substance abuse disor- 5* ders as well as the severity and 2 persistence of these other mental conditions.12 Current Lifetime excluding None People with current social anxiety (past 12 months) current disorder were over six times as likely History of social anxiety disorder as the general population to have a major depressive disorder, and they Note: Household population aged 15 or older, Canada excluding the territories. were three times as likely to suffer * Significantly higher than estimate for opposite sex (p<0.05). from substance dependency. Even Source: Statistics Canada, Canadian Community Health Survey: Mental Health and Well-being, 2002. individuals who no longer had symptoms remained at increased risk of having these other disorders. The relationship between social anxiety mental disorders. In 2002, respon- People with social anxiety disorder and these other mental dents with a lifetime history of social disorder lack conditions persisted when examined anxiety disorder and major depres- Previous studies have found that in multivariate models that controlled sive disorder reported that the social anxiety disorder is associated for socio-economic factors. symptoms of social anxiety occurred with social , disability, and It is thought that social anxiety first in about 7 of 10 cases (69%). The reduced quality of life. CCHS data disorder is more likely to be related age of onset for both disorders was provide further evidence of these to depression for women and to the same in 13% of cases. associations. substance abuse for men.13 When the When individuals had lifetime Four types of social support were CCHS multivariate models tested for histories of social anxiety disorder measured in the CCHS: tangible an interaction between sex and and , social anxiety was support, , positive social history of social anxiety disorder, the evident at a younger age for 59%, and interaction, and emotional or only significant interaction was for the age of onset was the same for informational support. Tangible depression. Among those currently both panic and social anxiety support is the most concrete type, reporting social anxiety disorder, men approximately one-quarter of the and involves having someone to had a higher risk than women of also time. provide help when you need it— for suffering from depression. In Although it has not been studied example, if you are confined to bed contrast, among those with a past extensively, an association between or need someone to take you to the history or no history of the disorder, social anxiety disorder and physical doctor, prepare meals, or help with depression was more prevalent illness has been found.14 CCHS daily chores. Affection is having among women. respondents with current social someone who shows you and anxiety disorder reported an average affection, gives you hugs, or Other mental disorders often of 1.5 physical chronic conditions, you and makes you feel wanted. follow social anxiety disorder significantly higher than the average Having someone to relax or have a According to CCHS data, social number reported for those with a good time with, or who helps get your anxiety disorder often precedes other past history (1.2) or no history (1.1). mind off things, provides positive

Statistics Canada — Catalogue No. 11-008 Summer 2005 Canadian Social Trends 25 compared with those with no history Those with current social anxiety disorder are seven of the disorder. Individuals who CST times more likely to report fair/poor mental health previously had social anxiety disorder than those who have never experienced the disorder were more likely to report long-term activity limitations and disability days in the past two weeks compared with % 37* Social anxiety disorder those with no history of the disorder, Current (past 12 months) although their impairment rates were Lifetime excluding current 29* substantially below those of people Never who currently had the disorder.

22* Dissatisfaction with life and health 17* 16* People with social anxiety disorder 13 tended to have a lower quality of life, 9* as indicated by their rather negative 5 perceptions of their own health and 2 4 their dissatisfaction with life. Close to 30% of people who currently had Fair/poor self-perceived Fair/poor self-perceived Dissatisfaction with life social anxiety disorder rated their physical health mental health physical health as fair or poor, compared with 17% of those who Physical/mental health previously had the disorder, and 13% of those with no history of it. More Note: Household population aged 15 or older, Canada excluding the territories. than a third of people (37%) with * Significantly higher than estimate for "never" (p<0.05). current social anxiety disorder rated Source: Statistics Canada, Canadian Community Health Survey: Mental Health and Well-being, 2002. their mental health as fair or poor, compared with 16% who previously had the disorder and 5% with no history of the condition. social interaction. Emotional or Activity limitations more Dissatisfaction with life in general informational support comes from common was also related to social anxiety people who understand you and your Compared with people with no disorder. More than 20% of people problems, who can give you advice, history of the disorder, those with with current symptoms indicated that and share your worries and fears. current social anxiety disorder were they felt dissatisfied, compared with Based on CCHS data, people with over twice as likely to report a long- 9% of people with a past history and social anxiety disorder lack adequate term activity limitation. This means 4% of those with no history. social support. Compared with that they were limited in what they individuals with no history of the could do at home, school, or work or Measuring the burden disorder, those who currently had it in leisure time because of a long-term The relationship between social were over twice as likely to have low physical or mental condition or anxiety disorder and social support, levels of each type of support. health problem. They were also over disability, perceptions of physical and Although the situation was somewhat two times as likely to report at least mental health, and satisfaction with better for people who no longer had one disability day over the past two life persisted even after the effects symptoms, they were still more likely weeks; that is, they had spent at least of socio-economic characteristics to have low social support, compared one day in bed, or had cut down on (sex, age, marital status, education with those who had no history of the their usual activities because of and income) were taken into account. disorder. Clinical studies have found illness or injury. When measures of major depressive that people with social anxiety Differences in disability days due disorder, panic disorder, substance disorder actually want social contact, to mental or emotional health prob- dependency and other physical but their fear of interacting prevents lems or use of alcohol or drugs were chronic conditions were introduced, this from happening and leads to even more pronounced. People with the strength of the relationships did social isolation.15 The early age of current social anxiety disorder were diminish, but in most cases, the onset makes it particularly difficult over 10 times more likely to report associations remained statistically to establish and maintain meaningful at least one disability day in the past significant. relationships. two weeks due to mental health,

26 Canadian Social Trends Summer 2005 Statistics Canada — Catalogue No. 11-008 The appropriateness of controlling average, 14 years after the age of Summary for other conditions and disorders onset. These low treatment rates for Social anxiety disorder has been when attempting to measure the social anxiety disorder are consistent described as an “illness of lost burden of social anxiety disorder has with findings from other studies.19 opportunities.” Results from the 2002 been debated. In most cases, social Failure to seek treatment may be Canadian Community Health Survey: anxiety disorder develops before directly related to the nature of social Mental Health and Well-being provide other mental disorders, although a anxiety disorder. Because of their further evidence supporting this cause-and-effect relationship has not extreme social fears, people may be description. The disorder often been established.16,17 Nonetheless, reluctant or embarrassed to discuss begins in childhood or early some researchers have hypothesized their symptoms with a health care adolescence: the self-reported that causal pathways may exist. For professional; in fact, the effort of average age of onset established example, many people with social contacting and meeting such a using the CCHS data is 13. And anxiety disorder use alcohol or drugs professional face-to-face may be symptoms persist—an average of two to help them cope, and this may lead extremely difficult for someone with decades among CCHS respondents to abuse or dependency.18 In addi- social anxiety disorder. As well, with a lifetime history of the tion, the social isolation associated individuals with the disorder often condition. with social anxiety disorder and attribute their intense fears to This study of national data found failure to achieve education and shyness. Because they are not aware that social anxiety disorder is related employment goals may increase the that they have a recognized mental to lower educational attainment, risk of depression. disorder, they do not consider reduced employment opportunities, The findings based on CCHS data professional help. low income and dependence on are particularly relevant because, CCHS results, like those of other welfare or social assistance, even when other mental and physical studies, indicated that seeking decreased likelihood of marriage or health problems are taken into treatment for social anxiety disorder of having a successful marriage, and account, the odds for all 10 outcome was far more likely if the person had social isolation. It is also associated variables were elevated among another mental disorder. Among with higher rates of disability, rather people with current social anxiety individuals with a lifetime history of negative perceptions of physical and disorder. both social anxiety and another mental health, and dissatisfaction mental disorder, 51% had sought with life. Majority do not seek treatment professional treatment for their Although effective treatment is People with a lifetime history of social fears—more than twice the available, most people with social social anxiety disorder were asked if rate for those with social anxiety anxiety disorder do not seek they had ever seen or talked on the alone (25%). The gap was even professional help to deal with their telephone to a doctor, psychologist, broader among those who had fears. The effort and commitment psychiatrist, social worker or other sought treatment in the past year: required to start and maintain a professional about their fear or 43% of people with social anxiety in formal treatment program can be avoidance of social situations. The addition to another disorder reported extremely challenging for patients majority had not. Only 37% reported receiving professional treatment with social anxiety disorder, and if that they had sought professional versus 16% of individuals with social that initial hurdle can be overcome, treatment, far below the rates for anxiety disorder alone. finding a trained professional may be major depressive disorder (71%) or The low treatment rates for social difficult. However, other studies panic disorder (72%). Just 27% of anxiety disorder and the number of suggest that early intervention and individuals with current social anxiety years people wait before seeking treatment may not only allow people disorder (those who reported having treatment are troublesome given with this disorder to realize their full symptoms in the past 12 months) that, in many cases, the disorder can potential, but it may also prevent had received professional help in the be treated successfully. In fact, subsequent mental disorders. past year. Those who did seek among CCHS respondents who did treatment often waited years before have professional help, the majority doing so. Among CCHS respondents (69%) felt that their treatment was with a lifetime history of social helpful and effective. Margot Shields is a senior analyst anxiety disorder, help was sought, on with Health Statistics Division, Statistics Canada.

Statistics Canada — Catalogue No. 11-008 Summer 2005 Canadian Social Trends 27 6. Lipsitz, J.D. and F.R. Schneier. 2000. 12. Kessler, R.C., P. Stang, H.U. Wittchen et 1. American Psychiatric Association. 2000. “Social phobia: Epidemiology and cost al. 1999. “Lifetime comorbidities between Diagnostic and Statistical Manual of of illness.” Pharmacoeconomics 18, social phobia and mood disorders in the Mental Disorders, Fourth Edition, Text 1: 23-32. U.S. National Comorbidity Survey.” Revision. Washington, DC: American 7. Schneier, F.R., J. Johnson, C.D. Hornig Psychological Medicine 29, 3: 555-567. Psychiatric Association. et al. 1992. “Social phobia. Comorbidity 13. Keller. 2003; Yonkers et al. 2001. 2. Chartier, M.J., A.L. Hazen and M.B. Stein. and morbidity in an epidemiologic 14. Lang, A.J. and M.B. Stein, 2001. “Social 1998. “Lifetime patterns of social phobia: sample.“ Archives of General Psychiatry Phobia: Prevalence and diagnostic a retrospective study of the course of 49, 4: 282-288. threshold.“ Journal of Clinical Psychiatry social phobia in a nonclinical 8. Wittchen, H.U. and L. Fehm. 2003. 62 (Suppl. 1): 5-10. population.” Depression and Anxiety 7, “Epidemiology and natural course of 3: 113-121. 15. Liebowitz, M.R. 1999. “Update on the social fears and social phobia.” Acta diagnosis and treatment of social anxiety 3. Kessler, R.C. 2003. “The impairments Psychiatrica Scandinavica Supplementum disorder.” Journal of Clinical Psychiatry caused by social phobia in the general 108 (Suppl. 417):4-18. 60 (Suppl. 18): 22-26. population: implications for intervention.“ 9. Weiller, E., J.C. Bisserbe, P. Boyer et al. Acta Psychiatrica Scandinavica 16. Lipsitz et al. 2000. 1996. ‘Social phobia in general health Supplementum 108 (Suppl. 417): 19-27. care: an unrecognised undertreated 17. Schneier et al. 1992. 4. Keller, M.B. 2003. “The lifelong cause of disabling disorder.” British Journal of 18. Bell, C.J., A.L. Malizia and D.J. Nutt. social anxiety disorder: a clinical Psychiatry 168, 2: 169-174. 1999. “The neurobiology of social perspective.” Acta Psychiatrica 10. Davidson, J.R.T. 2000. “Social anxiety phobia.” European Archives of Psychiatry Scandinavica Supplementum 108 disorder under scrutiny.” Depression and and Clinical Neuroscience 249 (Suppl. 1): (Suppl. 417): 85-94. Anxiety 11, 3: 93-98. S11-S18. 5. Yonkers, K.A., I.R. Dyck and M.B. Keller. 11. Katzelnick, D.J. and J.H. Greist. 2001. 19. Lecrubier, Y. 1998. “Comorbidity in social 2001. “An eight-year longitudinal “Social anxiety disorder: An unrecognized anxiety disorder: Impact on disease comparison of clinical course and problem in primary care.” Journal of burden and management.” Journal of characteristics of social phobia among Clinical Psychiatry 62 (Suppl 1): 11-16. Clinical Psychiatry 59 (Suppl. 17): 33-38. men and women.” Psychiatric Services 52, 5: 637-643.

28 Canadian Social Trends Summer 2005 Statistics Canada — Catalogue No. 11-008