Behavioral Components of Social Phobia: a Case Series

HARAI HiroakiHARAI Hiroaki 11

Behavioral Components of Behavioral Components of Social Phobia: a Case SeriesSocial Phobia: a Case Series

HARAI HiroakiHARAI HiroakiKikuchi National HospitalKikuchi National Hospital，，

Division of Clinical ResearchDivision of Clinical Research


Diagnostic Issue of Social Diagnostic Issue of Social Phobia & Phobia & TaijinTaijin--KyofuKyofu--ShoSho

Social Phobia as PhobiaSocial Phobia as PhobiaFear eliciting cues Fear eliciting cues CognitionCognitionAutonomic ArousalAutonomic ArousalAvoidanceAvoidance

TaijinTaijin--KyofuKyofu--ShoSho (TKS)(TKS)as Relevance to othersas Relevance to others


Another Aspect of Social Another Aspect of Social Phobia & TKSPhobia & TKS

Feared Social situationFeared Social situationCasual conversation in a group Casual conversation in a group

Interpersonal BehaviorInterpersonal BehaviorObservation behaviorObservation behaviorInterrupting and Initiating ConversationInterrupting and Initiating Conversation


Fundamental QuestionFundamental Question

Is TKS unique to Japan?Is TKS unique to Japan?Diagnostic reliability and validity of TKS Diagnostic reliability and validity of TKS and Social Phobiaand Social PhobiaIs Japan different from US?Is Japan different from US?

If different If different Course and TreatmentCourse and Treatment


Health Care UtilizationHealth Care Utilization

Healthexpenditu

re percapita

Physicians *

Hospitalbeds *

CoronaryArteryBypass

Operation*

Cholecystectom

y *

Inpatientadmission

rate %

Averagelength of

stayPPP $1990-98 1990-98 1990-98 1980 1980 1990-98

days1990-98

Australia 1,866 2.5 8.5 17 16Japan 1,757 1.8 16.2 1 2 9 44US 4,121 2.6 4 61 203 12 8

*Rates are per 1,000 people

Outpatientvisits

percapita

1990-98

716

6


Psychiatric Care and InstitutionPsychiatric Care and Institution

Averagelength of

stay,Psychiatry

SecondarySchool

Enrolment%

PrisonPopulation

Homicidereports

*

ArrestedDrug

offenses*

days 1991 1998 1992 2000 2000Australia 91Japan 325.5 97 36 1.0 23.9US 12.7 90 519 6.8 591Canada 91 116

*Rates are per 100,000 people

*

PsychiatricBeds

*

51 1994

264 1999

63 1995


What is Different?What is Different?

Illness ?Illness ?How the society respond to it ?How the society respond to it ?

Culture of Health CareCulture of Health CareCognition of the Health Care Professionals Cognition of the Health Care Professionals and Lay peopleand Lay people


Case PresentationCase Presentation

BackgroundBackgroundNational Psychiatric Hospital, Out patient National Psychiatric Hospital, Out patient clinicclinicPatients are referred from other hospitals and Patients are referred from other hospitals and clinicsclinicsNational Health Insurance CoverageNational Health Insurance Coverage


Case 2Case 2

38 Years Old Male, Administrative staff 38 Years Old Male, Administrative staff of a Universityof a UniversityCC:#1CC:#1 Feel tense in a groupFeel tense in a group

#2#2 Can not Talk to and look at Can not Talk to and look at the super visorthe super visor

#3#3 Get nervous when Others Get nervous when Others are present in work placeare present in work place

MDD, OCD (Checker)MDD, OCD (Checker)


Case 2 (continued)Case 2 (continued)

Behavior Observation in Social situationBehavior Observation in Social situationNever makes eye contact, always look down Never makes eye contact, always look down Monotonous tone of vocal toneMonotonous tone of vocal toneOften make vocal tics, eyelid tics, during Often make vocal tics, eyelid tics, during speaking. Autonomic arousal was observedspeaking. Autonomic arousal was observedIn a group, avoid eye contact, others feel In a group, avoid eye contact, others feel rejected. While others are speaking never rejected. While others are speaking never interrupt, never start speakinginterrupt, never start speakingIf prompted, starts speaking. But never stops. If prompted, starts speaking. But never stops. Only strong prompts can stop.Only strong prompts can stop.


Case 2 (continued)Case 2 (continued)TreatmentTreatment

Social skills trainingSocial skills trainingMaking eye contactMaking eye contactObserve OthersObserve Others

First step: Look at your face in the mirrorFirst step: Look at your face in the mirrorObserve Ones own behavior, monitoring ticsObserve Ones own behavior, monitoring ticsGeneralize the skill to the other situationGeneralize the skill to the other situation

Constructing responsesConstructing responsesGroup sessionsGroup sessionsIn vivo training, in restaurantsIn vivo training, in restaurants

ClomipramineClomipramine 225mg and Behavior therapy for 225mg and Behavior therapy for OCDOCD


Case 3Case 3

18 Years Old Male, 12 grade High School 18 Years Old Male, 12 grade High School student, preparing for entrance examstudent, preparing for entrance examCC:CC:

#1#1 Feel tense in a groupFeel tense in a group#2#2 Can not Concentrate, Fear of Failing Can not Concentrate, Fear of Failing

ExamExam#3#3 Get nervous about neighboringGet nervous about neighboring

students while in Classstudents while in Class#4#4 OneOne’’s emission of Odor offenses s emission of Odor offenses

Others, and Others say it badlyOthers, and Others say it badly


Case 3 (continued)Case 3 (continued)Sep.8 Sep.8

HAMHAM--D:11, SADS:15, FNE:12D:11, SADS:15, FNE:12FQ: Agora 14 Blood 3 Social 18FQ: Agora 14 Blood 3 Social 18TreatmentsTreatments

Self monitoring, Hierarchy Building, Self monitoring, Hierarchy Building, Self Exposure instruction, Role play and ModelingSelf Exposure instruction, Role play and ModelingFluvoxamineFluvoxamine 150mg150mg

Oct. 31Oct. 31HAMHAM--D:3, SADS:8, FNE:12D:3, SADS:8, FNE:12Among CCs, #2 #4 gone, #1 #3 lessenAmong CCs, #2 #4 gone, #1 #3 lessen


Case 2 (continued)Case 2 (continued)July 2001July 2001

HAMHAM--D:2, SADS:12, FNE:15D:2, SADS:12, FNE:15FQ:18,6,18FQ:18,6,18

HierarchyHierarchy9 Walk through shopping malls9 Walk through shopping malls6 Casual Party with Friends 6 Casual Party with Friends ““KonpaKonpa””5 Join a group who are chatting5 Join a group who are chatting5 5 ““KaraokeKaraoke”” party with Friendsparty with Friends~~~~2 Library, Succor game2 Library, Succor game


Some Some ““Culture Bound Culture Bound SyndromeSyndrome””

Pachinko AddictionPachinko Addiction


Treatment IssuesTreatment IssuesExposureExposure

Butler,G.:ExposureButler,G.:Exposure as a treatment for social as a treatment for social phobia:somephobia:someinstructive instructive difficulties,Behavdifficulties,Behav ResRes Ther,23:651Ther,23:651--657,1985657,1985

Cognitive RestructuringCognitive Restructuring


Eye Movement Pattern During Eye Movement Pattern During Interpersonal InteractionsInterpersonal Interactions

Recorded gaze patterns during mock Recorded gaze patterns during mock conversations with an eye mark recorderconversations with an eye mark recorder

Measured the time of gaze at four periods;Measured the time of gaze at four periods;1)while the subject was listening to the confederate,1)while the subject was listening to the confederate,2)the latency period before the subject started to 2)the latency period before the subject started to

make a verbal responsemake a verbal response3)while the subject were speaking3)while the subject were speaking4)following one second after the subject finished 4)following one second after the subject finished

speakingspeaking

Repeated the measurements in 3 consecutive Repeated the measurements in 3 consecutive conversations.conversations.


SubjectsSubjectsSocial Phobia and other anxiety disorderSocial Phobia and other anxiety disorder

Subjects were patients who were treated at the behavior therapy Subjects were patients who were treated at the behavior therapy unit in unit in Hizen National Mental Hospital during 1988 to 1995 and met the Hizen National Mental Hospital during 1988 to 1995 and met the diagnostic criteria of any of anxiety disorder in DSMIIIR3. We tdiagnostic criteria of any of anxiety disorder in DSMIIIR3. We tested the ested the subjects after their active symptoms such as severe anxiety statsubjects after their active symptoms such as severe anxiety state, e, phobic avoidance, rituals or phobic avoidance, rituals or dysphoriadysphoria were treated with were treated with behhaviorbehhaviortherapy or medication.therapy or medication.Social phobia (SP group)Social phobia (SP group)

Male were 7, and female were 3. Mean age was 28.Male were 7, and female were 3. Mean age was 28.Other anxiety disorder (AX group)Other anxiety disorder (AX group)

Male were 16, and female were 33. Panic disorder with or withoutMale were 16, and female were 33. Panic disorder with or withoutagoraphobia was 9, obsessive compulsive disorder was 9, generaliagoraphobia was 9, obsessive compulsive disorder was 9, generalized zed anxiety disorder was 3, simple phobia was 1.anxiety disorder was 3, simple phobia was 1.

Normal controlNormal controlThirty four students of a college level nursing school were testThirty four students of a college level nursing school were tested. All of ed. All of them were female and mean age was 19. Students with a history ofthem were female and mean age was 19. Students with a history ofmental disturbances were excluded.mental disturbances were excluded.


MethodMethodgaze patterns during three role plays with an eye mark recorder gaze patterns during three role plays with an eye mark recorder We recorded the eye mark in three scenes which required the subjWe recorded the eye mark in three scenes which required the subject to be ect to be assertive.assertive.

Scene 1: Chattering with a close friend about one's achievementsScene 1: Chattering with a close friend about one's achievementsScene 2: Rejecting a rude sales personScene 2: Rejecting a rude sales personScene 3: Arguing against boss's rebukeScene 3: Arguing against boss's rebuke

Each role play has the style of single prompt and short responseEach role play has the style of single prompt and short response..The total gaze time (The total gaze time (millimilli second) were measured during four periods;second) were measured during four periods;

1. Prompt period: while the confederate was talking,1. Prompt period: while the confederate was talking,2. Latency period: from the end of the prompt to the beginning o2. Latency period: from the end of the prompt to the beginning of the verbal f the verbal

response of the subjectresponse of the subject3. Response period: while the subject was making verbal response3. Response period: while the subject was making verbal response4. After response period: from the end of the response to 1 seco4. After response period: from the end of the response to 1 second afternd after

We divided the total gaze time of the each period with the duratWe divided the total gaze time of the each period with the duration of each ion of each period (second.) We used the divisions (millisecond/1second) forperiod (second.) We used the divisions (millisecond/1second) for further further analysis.analysis.


ResultResult

500550600650700750800850900950

1000

Pro

mpt

Late

ncy

Res

pons

e

Afte

r

Gaz

e tim

e m

seco

nd/1

sec

Fig.1 Gaze time in each period. The pattern of gaze that the gaze time decreases during response isobserved in all groups, however the pattern is less evident in SP group

Other anxietydisorder(AX)Control

Social phobia (SP)


DiscussionDiscussionSignificant difference of the standard deviation of Significant difference of the standard deviation of the gaze time among 3 groups.the gaze time among 3 groups.That of social phobia were the lowest, other That of social phobia were the lowest, other anxiety disorder was in between and controls anxiety disorder was in between and controls was the highest. The difference of the average was the highest. The difference of the average of the gaze time among 3 groups was not of the gaze time among 3 groups was not significant.significant.The pattern of gaze of patients with social The pattern of gaze of patients with social phobia is more fixed than that of patients with phobia is more fixed than that of patients with other anxiety disorders and normal controls.other anxiety disorders and normal controls.This finding suggests a deficit of social skills This finding suggests a deficit of social skills specific to social phobiaspecific to social phobia


Kumamoto Prefecture High Kumamoto Prefecture High School Student SurveySchool Student Survey

Community surveyCommunity survey3800 students in 5 schools were surveyed3800 students in 5 schools were surveyed95% of the general community attend high 95% of the general community attend high schoolschool90% of the registered student responded90% of the registered student respondedTwo waves, Dec. 1999, Sept. 2000Two waves, Dec. 1999, Sept. 2000

1190 subjects gave personal identification data, 1190 subjects gave personal identification data, and were able to be tracked the change in 1 yearand were able to be tracked the change in 1 year


Result of FQResult of FQ--Social phobiaSocial phobia

FQ AverageFQ AverageAgora 8.20Agora 8.20Blood 8.52Blood 8.52Social12.8Social12.8

FQFQ--S >19: 215S >19: 21554 out of 215 reported still high in FQ54 out of 215 reported still high in FQ--S S (>19) in second wave(>19) in second wave

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Behavioral Components of Social Phobia: a Case Series