Abstract

Background: Social anxiety disorder (SAD) is highly prevalent among adolescents but little is known about its prevalence in Saudi adolescents. Objectives: we aimed to determine the prevalence of SAD and investigate its associated correlates among Saudi adolescent females. Methods: A cross sectional study design was conducted at Taif university in the period from January to May 2016. A self-report pre-designed questionnaire was distributed to the students about personal factors and Social Phobia Inventory (SPIN) which is a reliable and valid psychometric tool of screening SAD. Results: Data of 957 female students were analyzed and rendered a prevalence of 16.3% for SAD among them. Most of the affected students had a moderate degree of the disorder in 43.5% of cases. Personal factors significantly associated with SAD in univariate analysis were obese weight perception (p <0.001), having body deformities (p = 0.004), insufficient income (p = 0.003), 1st birth order (p = 0.006), parental conflict (p = 0.003), parental death (p <0.001) and smoking (p <0.001). Conclusion and recommendations: Our results show there is a high prevalence of SAD among female university students in Taif, Saudi Arabia. Independent personal factors associated with SAD in our study were smoking, parent death and obese weight perception. Based on the high prevalence encountered in our study, we recommend early detection and intervention to reduce the overall burden associated with this psychiatric disorder in the adolescent population as emphasized by the literature.

1. Introduction

Adolescence is a sensitive period characterized by not only dramatic hormonal and biological maturation but identity and social relations are established as well during this period ¹.

Anxiety disorders are the most common mental disorders in adolescence with a global prevalence that ranges from15% to over 30%. Furthermore, social anxiety disorder (SAD) is the commonest anxiety disorder in the adolescent population ^{2, 3}.

SAD individuals have intense marked fear of scrutiny or evaluation by others in situations which are performance-based or social e.g., having a conversation or public speaking in front of audience and being observed (e.g., eating or working). SAD sufferers fear of involuntarily saying or acting in a humiliating or embarrassing manner such as looking stupid, boring or anxious or having sweating, blushing or shaking. They will attempt to escape these fearing situations whenever possible which is not always feasible, and they will have to endure the situation, but with intense distress feelings ⁴.

These defining symptoms of SAD were included in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM-IV) which has been published by The American Psychiatric Association. Earlier, in DSM-I and -II it was grouped with all other phobias, but later in DSM-III, it was considered as independent diagnosis. However, up to this day some mental health providers still name SAD as social phobia ⁵.

SAD is characterized by chronicity and psychiatric comorbidity and is one of the most common disabling anxiety disorders ⁶. It differs from performance anxiety and shyness by its greater severity. SAD places individuals in chronic distress and impairment ⁷ and is considered as the 5th most common disabling psychiatric disorder because it severely impairs all life domains ⁸. The most frequent comorbidities associated with SAD are other anxiety disorders, mood (depression) and substance abuse disorders ⁹.

SAD individuals often avoid important activities like school and work, even if they managed to attend, they will not participate. Accordingly, they have lower achievements in occupational, academic and family function, they will be at greater risk for drug and alcohol misuse and they will have less opportunity to marry and less quality of life. They are also at greater risk of committing suicide ¹⁰. Moreover, a substantial economic burden is associated with SAD because sufferers are more likely to have reduced work productivity or increased absenteeism from work or be unemployed ^{7, 11}.

Unfortunately, it is under-recognized problem and there is a lack of awareness about it in the general population about it. So, most cases go untreated ^{7, 11}; only about half of those with the disorder ever seek treatment, and even those who seek treatment, only do it after 15-20 years of symptoms ¹².

Many models describe risk factors associated with SAD, these factors include genetic factors, parent-child interactions and adverse environmental factors together with societal and cultural influences ¹³.

Available data suggest that about 75% of the severe persistent forms of social anxiety have their age of onset in the mid-adolescence. It is recently thought that adolescence could be an optimal period for targeting risks of SAD through interventions because it is a period of flexibility and heightened learning ¹⁴. In fact, a considerable number of persons who develop SAD in adolescence can recover before adulthood. However, if SAD persists into adulthood, the chance of spontaneous recovery is modest when it is compared with the other common mental disorders ¹⁵.

Information on SAD in Saudi adolescents is limited ¹⁶. So, the current study was conducted to estimate the prevalence, severity, and risk factors associated with SAD in the Saudi adolescents.

2. Methods

A cross sectional study was conducted in the period from January to May 2016, among students from different specialties at female section of Taif university in Taif city which is located in the western region of Saudi Arabia. Students were asked to participate voluntarily in the study. Data were collected from 1000 students. However, missing data were seen in the records of 43 students in the 2^nd part of the questionnaire diagnosing social phobia so their records were excluded and the final number of the analyzed questionnaires was 957.

Data was collected through a self-report Questionnaire distributed to students. The 1st part of the questionnaire included personal data of the participants which were accused of having relationship with social phobia (age, birth order, nationality, college specialty, academic year, weight perception, skin color, deformities, disabilities, income, living with or frequent visits to grandparents, mother and father age, education and jobs, presence of parental conflict or death, smoking and marital status).

Social Phobia Inventory (SPIN) developed by Connor and his colleagues was used to assess social phobia of the students in the 2nd part of the questionnaire. SPIN consists of 17-items scale and is rated from 0 (not at all) to 4 (extremely), the sum score ranges from 0 to 68. Social phobia is considered when the student has a sum score of 20 and above on SPIN, mild social phobia is considered when the total score ranges from 21-30, moderate from 31-40, severe from 41-50 while 51or more is considered very severe form ¹⁷. SPIN is a reliable and valid psychometric tool of screening social phobia in adolescents. It has a Cronbach alpha of 0.85, a sensitivity that ranges from 73-85% and a specificity ranging from 69-84% in diagnosing social phobia ^{18, 19, 20}.

Ethical clearance was obtained from the ethical committee board at Taif university. Participants were informed about the objectives of the study prior to the data collection and verbal consent was obtained from them. Confidentiality of data was assured to the participants.

SPSS-20 version for Windows was used in analysis of the data. Numbers and percentages for individual responses of the students in the items of questionnaire evaluating SAD were calculated. Univariate analysis using chi squared test and spearman correlation coefficients was used to test association between SAD and the proposed risk factors. Multivariate analysis was performed by binary logistic regression to assess independent risk factors for SAD among students. Significance was set at 0.05 level.

3. Results

The median age of the participants was 21 ranging from 18 to 29 years. Forty hundred and forty-four (46.4%) of the students were in the 1st academic year. Figure 1 shows that 156 students (16.3%) had SAD. Figure 2 shows that most students suffering from SAD had a moderate degree in 43.5% of cases while very severe degree of SAD was observed in only 2.5%. Table 1 shows the distribution SPIN items among students. Some of the most common items were avoiding activities in which the person is in the center of attention (76.3%), fear of people in authority (71.8%), bothered by flushing in front of people (65.9%), avoiding going to parties (65.7%) and scared of criticism (63.6%).

Table 2 shows individual factors associated with SAD. Significant factors were obese category of weight perception (p <0.001), presence of deformities (p = 0.004) insufficient income (p= 0.003), 1st birth order (p = 0.006), presence of parental conflict (p = 0.003), parental death (p <0.001) and smoking (p <0.001).

Table 3 shows there was no significant correlation between SAD and either of age, educational year, mother age or father age.

Table 4 shows that the only significant predictors to SAD among students by multivariate analysis were smoking, parent death and obese weight perception.

4. Discussion

Social anxiety disorder is a common psychiatric illness which has its onset around adolescent age ²¹.

Varying figures for prevalence of SAD have been reported by the literature. This variation can be attributed to the difference in tools used in assessment, the diagnostic threshold set, the overlap of symptoms with other disorders, the difficulty in separation from shyness or poor social skills and the difference in the studied population ²².

Epidemiological studies in adult non-clinical samples, revealed prevalence rates ranging from as low as 0.4% to as high as 15.6 % ²³. In adolescents, even higher figures were reported; 17% among Polish adolescents ²⁴, 24% in Pakistan ²⁵, 20.9% among Turkish adolescents ²⁶, 17.7% in Jordan ²⁷ and 9.3% in Egypt ²⁸

In Saudi Arabia, a limited number of recent studies regarding the subject of social anxiety disorder in adolescents was found. AL-QAHTANI & SBFM, conducted a study in 2012 on secondary male students and found that 14% of them had SAD ²⁹. Another study was conducted in 2013 on secondary school boys which found that 11.7% of the students had SAD ¹⁶. A very high prevelance; 34% was reported by Alkhathami in 2014 who conducted his study on elementary and secondary school boys and girls ³⁰. In our study, 16.3% of the students had social anxiety disorder (Figure 1) which is comparable to the previously mentioned studies.

Some of the most common items of SPIN in our study were avoiding activities in which the person is in the center of attention (76.3%), fear of people in authority (71.8%), bothered by flushing in front of people (65.9%), avoiding going to parties (65.7%) and scared of criticism (63.6%) (Table 1). Our results agree with findings of an Iraqi study held among university students where avoiding activities in which the person is in the center of attention, being bothered by flushing in front of people, avoiding going to parties and being scared of criticism were among the common items encountered in 75.7%, 74%, 63.5% and 79.4% respectively ³¹.

Individual factors significantly associated with SAD in our study were perceived obesity (p <0.001), presence of deformities (p =0.004), insufficient income (p 0.003), 1^st birth order (p 0.006), presence of parental conflict (p 0.003), parental death (p <0.001) and smoking (p <0.001) as shown in univariate analysis in Table 2. However, the only significant predictors to SAD among students by multivariate analysis were smoking, parent death and obese weight perception (Table 4).

Dissatisfaction with weight was associated with social anxiety in many studies ^{32, 33}. Agreeing with our results, Bagchi stated that obesity is associated with greater prevalence of anxiety disorders specially social phobias ³⁴. Another recent study suggested a positive association between sedentary behaviors which are contributing factors to obesity and anxiety disorder ³⁵. However, Anderson et al in 2017 stated that obesity is associated with anxiety disorders in females not males ³⁶. Inversely, Lee and Yen, in their study on Taiwanese adolescents reported there is no association between obesity and social phobia ³⁷.

For assessing the relationship between deformities and SAD in our study, we used a single direct question to ask about presence or absence of any body deformities among participants. We didn’t use the body dysmorphic disorder questionnaire which is derived from the DSM-IV. That questionnaire asks respondents if their appearance concerns are sources of preoccupation and, if so, it determines the degree of associated stress and interference with social or occupational functioning of the individuals ³⁸. Body dysmorphic disorder (BDD) is characterized by excessive thoughts about an existing slight or even imagined defect in the appearance and it arises from a fear of negative evaluation by other people; the core feature of SAD ³⁹.

A recent study indicates an existing link between body dysmorphic disorder (BDD) and SAD ⁴⁰. Previous studies also report a SAD prevalence of 12 – 69% among individuals suffering from BDD and a BDD prevalence of 5 – 12% among those with SAD ^{41, 42}. These reports are agreeable with our significant findings (p value = 0.004) about the relationship between SAD and presence of deformities.

Poverty is linked to many adverse mental health conditions in adolescents either directly through its effects on adolescents or indirectly through stimulating parental stress which leads to parent–adolescent conflict and negative parenting practices ⁴³. Various adult and children studies showed significant associations between mental disorders and low socioeconomic status ⁴⁴. Moreover, a systematic review conducted on 115 epidemiological studies in middle and low income countries investigated the association between common mental disorders and poverty and reported that more than 70% of these studies found a positive association between common mental disorders and poverty ⁴⁵. So, a consensus exists now in the literature about high rates of anxiety disorders in those with a socio economic disadvantage ⁴⁶. The association between low socio-economic status (SES) and SAD which is consistent with our findings was explained by the strong impact of extreme poverty on the social functioning. This association is strongly seen in developing countries and in nations with extreme deprivation ⁵.

The family structure and the position of the child in that family have a significant impact on how the children develop and perceive the world (Adler, A., Liebenau, G., & Stein, H., 2005). Studies regard first-born children as more conscientious, dominant, responsible, ambitious, more neurotic and anxious about their status whereas later-born children emerge as being more agreeable, tender-minded, accommodating, altruistic, open to experience, nonconforming and unconventional, fun-loving and sociable ⁴⁷. Consistent with our result is a study done by Pearson in 2009 to explore relation between anxiety and birth order where they found that first-born children have higher levels of physiological and social anxiety compared to later-born children ⁴⁸. Inversely, Elalky et al. reported no association between birth order and both anxiety and depressive symptoms ¹.

Grover et al (2005) found that children who had loss experiences in the form of death, separation, academic failure and negative family environment had a greater degree of anxiety ⁴⁹. Several other studies have found that parent separation and divorce can impact children’s adjustment over time and that internalizing problems can develop in children with early parent divorce whereas later parent divorce is associated with poorer grades in school ^{50, 51, 52}. Another study investigated the relationship between marital quality and family adaptability and cohesion, and child social anxiety. The findings suggest that rigid families or marital discord (low quality marriages) are probable risk factors for high levels of social anxiety in children ⁵³. A more specific study done by Bandelow et al in 2004 reported similar findings to our study regarding parental separation. This study linked SAD with parental separation, parental marital discord, sexual abuse, familial violence, and childhood illness. All these adverse events were correlated with high rates of SAD but parental separation had the highest correlation in that study ⁵⁴.

Harmful behaviors such as drinking, drug use and smoking generally start in adolescence. This early start predicts later abuse and dependence. So, it is very important to study facilitating and impeding factors for the beginning of these behaviors during this critical period of life. One of the factors linked to smoking in adolescence is social anxiety ⁵⁵. Studies report that SAD individuals have higher rates of drinking, smoking, and drug use than non-SAD individuals ^{56, 57, 58}. Moreover, a recent study in high school students reported association between social anxiety and positive attitudes towards cigarette smoking ⁵⁹.

Moylan et al described 3 different models that can explain the association between smoking and anxiety, the first model suggests that smoking increases anxiety, the second one suggests that anxiety increases smoking and the third one suggests that smoking and anxiety rates are affected by shared risk factors ⁶⁰.

Several studies report that individuals with high anxiety are more likely to smoke ^{58, 61, 62, 63}. Many factors were accused in this association such as the use of cigarettes as a self-treatment to reduce anxiety and the increased effect of peer pressure in those suffering from anxiety ^{64, 65}. Moreover, many studies suggest that smoking increases the risk of developing high anxiety ^{62, 66, 67}, 66, 67] this link may be due to the effects of smoking on neurotransmitters, neurobiology, respiratory health and autonomic control ⁶⁸ and due to the impact on normal neurodevelopment ⁶⁹. Finally, many shared risk factors have been identified that can increase the probability of both smoking and anxiety such as low socio economic status ^{70, 71, 73}.

It is noteworthy that our research has some limitations. Some risk factors which have been associated with SAD in literature such as sexual, emotional and physical abuse ⁷⁴ and family violence ³³ haven’t been investigated in our study. We didn’t approach these areas because of the high sensitivity of these issues to be discussed in the studied population.

5. Conclusions

Our study showed there is a high prevalence (16.3%) of SAD among Taif female university students. Most of them had a moderate degree of the disorder. Personal factors which were significantly associated with SAD in univariate analysis were obese weight perception (p <0.001), presence of body deformities (p 0.004), insufficient income (p 0.003), 1st birth order (p 0.006), parental conflict (p 0.003), parental death (p <0.001) and smoking (p <0.001). Our results call for early detection and intervention to reduce the overall burden associated with this psychiatric disorder in the adolescent population.

References