Iulian Iancu, M.D.Ehud Bodner, Ph.D.,Samia Joubran, M.Ed.Edward Ram, M.D.,

Social Anxiety Disorder‐ the West  and the Eastand the East

SAD in Western societies

S i l  i  di d  (SAD) h  b   dl   Social anxiety disorder (SAD) has been repeatedly shown to be very prevalent in the Western society with prevalence rates of 10% or above  prevalence rates of 10% or above. 

H    f   di  h  b  d  i   h   However, very few studies have been done in the Middle East and in Arab countries.

An anecdotal report in 1987 suggests a high incidence rate of SAD in Saudia

Epidemiological and clinical studies on SAD are scant in theMiddle East and in Arab communities.

SAD was reported to constitute about 13% of all neuroticdisorders seen at a large clinic in Riyadh.

It was argued that the Saudi culture requires adherence to rigidIt was argued that the Saudi culture requires adherence to rigidmoral codes and rituals at the expense of personal autonomy.

Furthermore, one who has made a bad impression in public islikely to retain a poor reputation permanently.likely to retain a poor reputation permanently.

These factors may affect those with a strong sense ofindividuality.

Consequently SAD has been reported to be more prevalent in Consequently, SAD has been reported to be more prevalent inyoung and well‐educated Saudis who are less willing to conformto a ritualistic social milieu.

Moreover the low incidence of SAD in Saudi women might result Moreover, the low incidence of SAD in Saudi women might resultfrom the constricted social situations to which Saudi women areexposed.

Since then, studies show quite the opposite, a low incidence rate of SAD in Arab societiesincidence rate of SAD in Arab societies

Karam et al (2008) reported in Lebanon a lifetime prevalence of SAD of 1 9% (2 1% in females and 1 7 % prevalence of SAD of 1.9% (2.1% in females and 1.7 % in males).

The lifetime prevalence was 2.8% among subjects aged p g j g18‐34, 1.5% among 35‐49, 1% among those aged 50‐64 and 0.4% among those aged 65 and above. 

Karam et al also found a very long delay for treatment of anxiety disorders in general, perhaps due to stigma, financial difficulties and lack of awareness  financial difficulties and lack of awareness. 

A recent large study (N=4332) from Iraq reported a low lifetime prevalence of only 0 8% (2009)lifetime prevalence of only 0.8% (2009).

SAD in Israel‐ very few studiesy Levav et al (1993) examined the prevalence of mental

disorders in a 10‐year cohort of young adults in Israel  This disorders in a 10 year cohort of young adults in Israel. This study also examined the 1‐year prevalence of phobic disorders (including SAD) and reported that the point 

l   f  h bi  di d     8%  l  f   h  prevalence of phobic disorders was 2.8%, less frequent than in American, European, and Australian samples. Specific data on SAD prevalence were not provided.p p

I reported in 2006 in a large group of Israeli soldiers that SAD was present in 4.5% of the sample (based on LSAS alone). 

We were surprised that the recent Israeli National Health Survey (2007) did not include SAD in the list of disorders assessedassessed.

The Arab society in Israely Due to the contradictory evidence on the prevalence of SAD 

between different countries and cultures, research in Israel, a lti lt l  i t     id  i t t i i ht  multi‐cultural society, may provide important insights. 

Arabs in Israel are a relatively collectivistic‐communal, homogenous cultural group. 

The Arab society is a non‐assimilating minority, differing from the Jewish majority in language, education and religion. 

This minority perceives high school education as an opportunity y p g pp yfor employment and a higher economic status.

According to an early study on Jewish and Arab students in Israel (1989), the two samples did not differ on social anxiety scores. ( 9 9), p yMales had higher scores and the author proposed that this derived from the traditional role of the male as initiator of heterosexual relationships. heterosexual relationships. 

The objectives of the studyj y1. To assess the prevalence of SAD in an Israeli sample 

of Jewish and Arab studentsof Jewish and Arab students.

T   i   ibl   i k f  f   h  d l  2. To examine possible risk factors for the development of SAD in both groups.

3. To examine the correlation between shyness (a f d d d l d ) d lfeature disregarded in Israeli studies) and social anxiety in the Jewish and Arab students.

hHypotheses 

1. SAD symptoms will be less frequent among the Arab students as compared with the Jewish studentsstudents as compared with the Jewish students(due to their collectivistic type of life).

2. Arab students will include more male subjects with SAD  h   h  J i h  l  SAD than the Jewish sample (based on Chaleby).

       Shyness and SAD will be highly correlated3.       Shyness and SAD will be highly correlated.

Methods Subjects: 300 undergraduate students from colleges in Northern Israel, 74 males and 226 females, age range 19‐54 ( )(M= 24.5, SD=5.83 ).

No exclusion criteria were used. Tools: The participants filled a battery of self report  Tools: The participants filled a battery of self‐report questionnaires: A socio‐demographic questionnaire

h b l l ( ) The Liebowitz Social Anxiety Scale (LSAS) SAD‐positive when LSAS>60

The Cheek Buss Shyness Questionnaire (CBSQ) The SAD part of the Mini‐International Neuropsychiatric The SAD part of the Mini International Neuropsychiatric Interview (MINI).

A subject was considered MINI‐positive if all criteria for SAD were met on the MINI (however we used the LSAS as the main tool to SAD were met on the MINI (however we used the LSAS as the main tool to “diagnose“ SAD). 

Results – Background h t i ticharacteristics

A b  ( )  ( )Arabs (N=147) Jews (N=153)M SD M SD P

Age 23 46 6 52 25 51 4 89 p<0 01Age 23.46 6.52 25.51 4.89 p<0.01Education (years) 14.12 1.87 13.55 1.15 p<0.01(y ) p

In comparison to Jews, Arabs reported of: being less frequently involved in a romantic relationship more religious more married bad perceived economic situationbad perceived economic situation less in psychological treatment

Results – LSAS and CBSQQ Shyness and Social Anxiety: The scores of the subjects on the LSAS subscales (Fear and Avoidance)  the total on the LSAS subscales (Fear and Avoidance), the total LSAS score and the CBSQ score (shyness score) did not differ between Jewish and Arab studentsdiffer between Jewish and Arab students.

LSAS Scores: 18 Jewish (11.8 %) and 19 Arab  (12.9%) students scored above the 60 cutoff score (p= 0 76)  students scored above the 60 cutoff score (p= 0.76). 

No gender differences were found in the distribution of Arab and Jewish SAD‐positive participants (2 males of Arab and Jewish SAD‐positive participants (2 males and 16 females (11%) in the Jewish students vs 3 males (15%) and 16 females in the Arab sample, p>0.05).(15%) and 16 females in the Arab sample, p>0.05).

: SAD and Shyness in Jewish and Arab students1Table

Jews Arabs Significance

LSAS fear subscale 18.04 (11.6) 17.37 (11.8) NS

LSAS id b l 17 32 (10 8) 18 32 (11 8) NSLSAS avoidance subscale 17.32 (10.8) 18.32 (11.8) NS

LSAS total score 35.36 (21.1) 35.69 (22.0) NS

CBSQ score 47.9 (12.7) 47.72 (10.4) NS

Results CorrelationsResults ‐ Correlations LSAS scores and MINI diagnosis: Seven students (2.33%)h d i i MINI di i f SAD ( J i h d A bhad a positive MINI diagnosis of SAD (3 Jewish and 4 Arabstudents). Three of them had a LSAS score below the cutoffscore of the LSAS and 4 above (57%). As expected, the MINI‐4 (57 ) p ,positives had higher rates of LSAS‐positive SAD (abovecutoff score) (X2 = 13.3, df=1, p < 0.001).C l i Th P l i b h CBSQ Correlations: The Pearson correlation between the CBSQscore and the total LSAS score was 0.64 in the total sample(p<0 001) 0 67 (p<0 001) in the Jewish sample and 0 61(p<0.001), 0.67 (p<0.001) in the Jewish sample and 0.61(p<0.001) in the Arab subsample.

Regression Analysis: The total LSAS score was predicted by Regression Analysis: The total LSAS score was predicted bythe CBSQ score (p<0.001) and by female gender (p< 0.001).(R‐square = 0.44).(R square 0.44).

Childhood experiencesp

bj d h h i 102 subjects reported that their parents were over‐defending.

bj d h i i 129 subjects reported their parents as over‐expecting. 139 reported their parents as over‐critical. 40 reported that their parents had separated. No differences in LSAS scores between subjects withjand without these aversive negative experiences.

Additional results

Hi h LSAS Higher LSAS scores among:

Females Those without a spouse Those in psychological treatment Those who find the internet as enabling social contacts

Discussion ‐Main findingsg The sample was characterized by high SAD and shyness scores  Overall  12 3% of the sample had above cutoff scores shyness scores. Overall, 12.3% of the sample had above cutoff scores on the LSAS, similar in our 2 subsamples.

Two variables predicted the LSAS score: the CBSQ p Qscore and female gender. 

No differences were found in SAD and shyness yscores between the Arab and the Jewish students. 

The Arab students were less likely to receive ypsychological treatment.

The SAD and shyness questionnaires correlated y qsignificantly. 

How can one explain the high rateHow can one explain the high rate of SAD in our sample?p

The Israeli society is characterized by numerousimmigration waves unstable political environment andimmigration waves, unstable political environment andfrequent security threats, which may affect socialinteractions and possibly increase the rate of SAD.p y

Individualistic strivings may also cause SAD. Relative to European youth, Israeli adolescents displayedp y , p ylow problems of social rejection, whereas the rate of lonelystudents was among the highest (Harell et al, 1997).

It is possible that the high rate of loneliness coupled withsecurity threats and high individualism may contribute to af f i l i tform of social concern or anxiety.

How can one explain the similarityHow can one explain the similarity of SAD in our groups?g p

Al h h hi i i d i h h fi di f Although this is in accordance with the findings of astudy from the 80’s, it contradicts two other (related)studies on Israeli Arab adolescents who demonstratedstudies on Israeli Arab adolescents who demonstratedhigher levels of test anxiety and trait anxiety ascompared to Jewish adolescents This has beencompared to Jewish adolescents. This has beenexplained by the fear that one’s failure will become thefailure of the whole family, thus the Arab person will feel morefailure of the whole family, thus the Arab person will feel morefear and shame…

SAD in females The higher prevalence of SAD among females is inaccordance with reports from the United Statesaccordance with reports from the United States,Europe, and the Middle East, but in contradiction to aprevious study in Israelprevious study in Israel.

It is possible that the Israeli and Arab youth are It is possible that the Israeli and Arab youth arenowadays in transition towards Western standards andthis comprises heavy expectations on femalesthis comprises heavy expectations on females.

How can the similarity of shynessHow can the similarity of shyness in both groups be explained?

It is possible that in a Western society shyness is regarded

g p p

It is possible that in a Western society, shyness is regardednegatively since the Western culture values socialcompetence and the independent and free expression off li d i h f l i h hi hfeelings and even in the company of people with a higherlevel of expertise.

In Southeast Asian countries however shyness is In Southeast Asian countries, however, shyness isconsidered as a virtue, an ability to control oneself in frontof others and to respect the social rank of others.

It is plausible that that the transition towards Westernstandards which occurs in both societies (Jewish and Arab)had a similar impact on our participantshad a similar impact on our participants.

The relationship between SAD and shynessshyness

The high correlation between shyness and SAD isThe high correlation between shyness and SAD isin accordance with the view that these are notseparate phenomena, but rather overlappingconditions.

Both conditions stem from heightened autonomicl i d i i i l it tiarousal experienced in various social situations,

lack of social skills and fear of negative evaluation. SAD is an extreme form of shyness, such thatSAD is an extreme form of shyness, such that

when the symptoms of shyness become more extremethe condition should be termed generalized SADrather than shyness.

Limitations

Th     f SAD    d  i h    lf   The rate of SAD was assessed with a self‐report inventory (the LSAS alone), and not with the CIDI.O   l       i   l   d    Our sample was a convenience sample and was moderate in size.Thi    di d     ffli d  i h    This survey disregards persons afflicted with severe disorders that cannot or would not attend colleges. 

Finally,y, Our findings add to the knowledge about culturalvariations in social anxiety and shyness across thevariations in social anxiety and shyness across theworld.

They also corroborate findings from other studies in They also corroborate findings from other studies inthe Western world, regarding the high prevalence ofSAD symptoms (even in an Arab sub‐sample)SAD symptoms (even in an Arab sub sample).

Further research is needed with standardized methodssuch as the CIDI to confirm our impression that SADsuch as the CIDI to confirm our impression that SADis frequent in these populations.

Implications for treatmentp Shyness and SAD are barriers to mental treatment.Th h f l i hibi d i h f The shy person feels inhibited in the presence ofothers.Th h id h i l hi h i The shy person avoids the social contact which isinherent in psychotherapy and prefers self‐help onassistance from othersassistance from others.

The shy person attempts to disguise his weaknesses.h f h l h l h It is, therefore, very important that mental health

officials should continue to improve the distribution oft t t f h d i ll itreatment for shy and socially anxious persons.