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Coping With Social Anxiety
The Definitive Guide to Effective Treatment Options
By Eric Hollander, Nick Bakalar
Henry Holt and CompanyCopyright © 2005 Eric Hollander, M.D., and Nicholas Bakalar
All rights reserved.
Who Gets Social Anxiety, and Why?
Some human characteristics are purely genetic. Eye color is one of them. No amount of "good" or "bad" parenting, no physical environment, north or south, hot or cold, will change the color of a baby's eyes. Others — the language we speak, for example — are purely environmental. There are no genes for speaking English, or French, or Navajo. But most human qualities, particularly those that have to do with behavioral and emotional traits, seem to lie somewhere in the messy middle — a complex combination of genetic and environmental factors that work together to make us what we are. It is often extremely difficult to say exactly what environment or genes contributes to a given characteristic, and so it is with social anxiety disorder (SAD). Much scientific effort has gone into trying to figure out how much the symptoms of social anxiety disorder can be attributed to our genes and how much can be attributed to our environment. While little is known definitively, researchers have developed considerable data that suggest at least some partial answers to this difficult question.
Childhood Trauma and Social Anxiety
Current estimates are that somewhere between 4 and 8 percent of adults suffer from SAD in any year, and that the percentage of people suffering from the disorder at some time in their lives is even higher. Such a rate makes social anxiety, after depression and alcoholism, the third most common psychiatric disorder. Knowing how many people suffer from a disease is, of course, not enough. We'd like to be able to predict which people are going to suffer from a given disease so that we can intervene early to prevent it. To do this, researchers look for risk factors — clues that suggest a disease is likely to occur. In the case of social anxiety (and many other psychiatric illnesses) one of the things they look for is developmental problems in childhood. If a particular kind of childhood problem leads to later social anxiety disorder, it is identified as a risk factor for the disorder, one of the contributing causes of a disease. This is what a team of Canadian researchers did in 2001 when they set about to examine the backgrounds of people with SAD. They depended for their data on a large health survey undertaken by the Ontario Ministry of Health.
The study found that certain childhood events are highly correlated with SAD later in life. Childhood sexual abuse, the lack of a close relationship with an adult, failure in early grades of school, and dropping out of high school were all associated with SAD. So were moving more than three times as a child, involvement with the juvenile justice system, and running away from home. Social class, on the other hand, had no bearing whatsoever on whether a person would suffer from the disorder. Being a firstborn male increased the risk for social anxiety; firstborn females experienced no such increased risk.
But things are never so simple. The authors of the study are careful to point out that these associations are not the same as causes. It is perfectly plausible, for example, that a child who runs away from home is already suffering from a form of social anxiety, so that it isn't running away that caused social anxiety, but the social anxiety that caused the running away. The same problem might apply to any other of the risk factors identified. So the authors' correlations, accurate though they are, tell little about whether these childhood events actually cause social anxiety.
Childhood trauma seems to play a role in other closely related anxiety diseases as well. Panic disorder and generalized anxiety disorder have both been found to be significantly related to past childhood physical or sexual abuse — in fact, in some studies these disorders appear to be more closely related to such abuse than social anxiety disorder.
Childhood behavior, even when it isn't pathological, might also be a predictor of social anxiety disorder. I see some kids who seem naturally curious; they like to explore new environments, meet new people. Others are more withdrawn. Inhibited behavior — a consistent tendency in children to display fear and withdrawal in any new situation — gives me a hint that social anxiety will develop. A carefully designed study published in 2001 demonstrated that behavioral inhibition was associated with a higher risk for SAD as well as other anxiety disorders. (There was also some good news for shy kids: behavioral inhibition has a lower association with disruptive behavior.)
The next question is why childhood personality or behavior predicts social anxiety in adulthood, and the answer is not at all self-evident. Many feel that childhood experience makes people modify their attitudes about the world and the extent to which they fear it. Some speculate that childhood trauma actually causes biological changes in the brain that lead to social anxiety, and this finds some support in animal studies. By manipulating the environment of young macaque monkeys, and then testing their reactions to anxiety-provoking drugs later in life, researchers were able to show that a stressful environment in juveniles was likely to produce anxious adults, and even actual permanent neuronal changes in the animals' brains caused by early experience.
The experiment worked like this. Two groups of five female macaques and their infants were the subjects. In the first group, mothers had easy access to their food rations. In the second group, mothers had to search for their food in a device that hid the rations under a pile of wood chips. This required considerable time — and considerable anxiety — in finding the food. Both groups of infants matured normally, but the second group were raised by anxious parents. Presumably this anxiety would affect their treatment of their infants.
When the infants were six months old, the researchers gave them anti-anxiety drugs. The infants raised by anxious mothers responded more to the drugs as measured by observations of their social behavior than did those raised by non-anxious parents. Apparently, anxious mothers had transmitted their anxiety to their children, even to the extent of causing biological changes that would result in a different response to anti-anxiety medicines.
But of course I treat people, not monkeys, and it has been almost impossible for researchers to connect a specific traumatic event in a person's life to the development of social anxiety disorder. A minority of patients report a specific event that they feel led to the development of their problem, but their reports are not always reliable. Often there is a long delay between the time a patient feels symptoms and the time he seeks help, and in the interval many traumatic events may have happened and been forgotten. It is probably true that traumatic events by themselves are unlikely to be the cause of social anxiety — significant proportions of people without social anxiety have experienced traumatic events, and some studies show as little as 15 percent of those with social anxiety can point to a specific traumatic event as the source of their problem.
Nevertheless, there are some suggestive findings about less dramatic or specific events. Constant rejection or bullying by peers, for example, may sensitize kids who are already at risk for social anxiety. One study found that "behavioral inhibition" in five- to twelve-year-olds (assessed by parents looking back at the past), long-lasting separation from parents, and a parental history of psychopathology were all associated with the incidence of social anxiety. Whether or not any of these things are actual causes of social anxiety, however, is another unanswered question.
Genes and Your Destiny
If it is differences in brain structure that cause a tendency to social anxiety, then it is clear that genetics may also play a part. Everyone notices that "the apple doesn't fall far from the tree," that not only physical appearance but also children's behavior tends to resemble that of their parents. But noticing such similarities is not the same as scientifically proving that they are inherited, and certainly far from proving exactly what the mechanism of inheritance is. The inheritance of physical traits — eye and hair color, height, weight, and so on — is complicated enough. When it comes to the inheritance of behavioral traits, the complexity increases enormously, and the uncertainties begin to multiply.
That shyness is inherited is not a new observation. In 1872, Charles Darwin published The Expression of Emotion in Man and Animals, in which he asserted that shyness — or at least its physiological manifestation in blushing — was an inherited characteristic. He quotes the observations of a physician: "Even peculiarities in blushing seem to be inherited. Sir James Paget, whilst examining the spine of a girl, was struck at her singular manner of blushing; a big splash of red appeared first on one cheek, and then other splashes, variously scattered over the face and neck. He subsequently asked the mother whether her daughter always blushed in this peculiar manner; and was answered, 'Yes, she takes after me.' Sir J. Paget then perceived that by asking this question he had caused the mother to blush; and she exhibited the same peculiarity as her daughter." In 1890, William James, in The Principles of Psychology, quoting Darwin approvingly, counted shyness as a basic human instinct.
SAD clearly runs in families. But to say that something "runs in the family" is not the same as saying it is carried in the genes. Sorting out what is genetic and what is environmental is the most difficult part of the problem. One way to do this is with twin studies. Since identical twins have exactly the same genes, differences in twins' behavior can, at least with greater justification than those between non-twins, be attributed to their environment. Most researchers agree that environment adds to whatever effect genes have — in other words, that the effect of genes is consistent no matter what the environment. If this is so, then the special case of identical twins who have been separated at birth and raised in different environments provides the ideal natural experiment to test such ideas: the genes are the same, only the environment is different. Such groups of identical twins have been studied to test all sorts of hypotheses about nature and nurture, among them the heritability of anxiety disorders.
Of course, even such an apparently perfect natural experiment has its complications and limitations. Events in a family may profoundly affect one twin while leaving the other untouched. Suppose, to take an extreme example, one twin is sexually abused by a parent while the other is not. Such an event could cause a predisposition to later psychiatric illness in the affected twin, but not in the other. Or suppose, less spectacularly, that each twin simply reacts in a different way to an event they both experience, one interpreting it as benign, the other as traumatic. Parents' frequent loud arguments with each other, for example, could be harmful or not, depending on each twin's interpretation of the meaning of these disputes.
Even twin studies sometimes contradict each other. For example, a 1992 study of 2,163 female twins concluded that 30 to 40 percent of the development of social phobia is genetically passed from parent to child. But then another study appeared to show that genetic contribution was minimal, and though some anxiety disorders seemed to be heritable, there was no difference in heritability of social anxiety between monozygotic (identical) and dizygotic (fraternal) twins. In other words, though there is some genetic component, it does not seem to be particularly strong.
More recent twin studies, conducted with more sophisticated methodologies, have shown a higher heritability of social anxiety. And they have shown that the most severe kinds of social anxiety are the most likely to run in families. Moreover, social anxiety was found to be more heritable than other kinds of anxiety disorders.
In addition to twin studies, there are studies that consider the families of people with social anxiety. It's pretty clear that having one parent with an anxiety disorder increases a child's risk of social anxiety, and that having two parents with an anxiety disorder increases it even further.
The handful of studies that specifically consider the heritability of social anxiety disorder (separate from other anxiety disorders) show that a person with a first-degree relative (a brother, sister, mother, or father) who has social anxiety is two to three times as likely to suffer from it as someone who has no such relative, and the heritability is greater for generalized social anxiety (the fear of most social situations) than for the specific form (the fear of only one or two social situations).
Parents and kids interact, whatever their genetic makeup, and different kids interact in different ways with the same parents. It's possible, for example, that a very shy and retiring child may inspire different behavior from his parents than his outgoing and sociable sibling. In such a case, parents and children work together to create two different environments for two different kinds of children. This, too, might be considered an effect of genes — the same genes that make a child shy also have an influence on his environment, in the sense that his shyness makes people interact with him in particular ways. Genetic predisposition affects environment; environment affects the expression of a genetic predisposition. One study made this stunningly clear, when researchers looked at adoptive parents of children whose biological parents suffered from substance abuse or antisocial personality. The researchers first showed that the bad behavior of the children was significantly related to the psychiatric diagnosis of their biological parents. This was interesting, but not surprising. But then they showed that children who behaved badly (presumably genetically induced behavior, since they had no contact with their biological parents) elicited less nurturance and more hostility from their adoptive parents. Thus the behavior of the adoptive parents was significantly influenced by the psychiatric status of the biological parents, even though they had never come into contact with each other! The biological parents' genes, in other words, had, insofar as their children inherited those genes, affected the behavior of the adoptive parents. The researchers were able to draw a direct line between the psychiatric status of the biological parents and the behavior of the adoptive parents. Sorting out nature and nurture, genes and environment can be a tortuous process.
Good Parents and Bad
How about poor parenting? Can that cause psychiatric illness? Maybe, but it's not easy to decide whether someone has had poor parenting. First, how do you define "poor parenting"? Why do the same parents have such apparently varying effects on siblings? How does a child's perceptions of his parents, accurate or not, affect psychopathology? Do parents engage in different kinds of child-rearing practices depending on the personality of the child? How much of parenting style depends on the relationship between a particular child and the parents? How do you separate all the other influences, environmental and genetic, from the "parenting" factor? And, as I suggested above in discussing how children and parents interact, the behavior of the kids themselves can under some circumstances make parents "good" or "bad." Such complications make it very difficult to pin it on the parents, and when studies are undertaken that try to take all these problems into account, researchers, even those using carefully designed twin studies, can't definitively say that people's psychiatric distress is caused by having had unskilled parents.
This doesn't mean that parents have no influence, however. It seems to be true that people who suffer from social anxiety have children who are more likely to suffer from it, too. In a study published in 2000, researchers concluded that social anxiety in parents is definitely a risk factor for social anxiety in their children. The authors didn't draw any conclusions about whether this association was due to genetics or environment — they only asserted that it exists. They speculate, however, that if there are environmental factors involved, they might include a restricted opportunity to learn social skills among children of parents who don't demonstrate such skills themselves and can't teach them to their kids. Depression, alcohol use disorders, and other anxiety disorders in parents were also associated with the development of social anxiety in their offspring, although the authors admit that other studies seem to contradict this finding.
Excerpted from Coping With Social Anxiety by Eric Hollander, Nick Bakalar. Copyright © 2005 Eric Hollander, M.D., and Nicholas Bakalar. Excerpted by permission of Henry Holt and Company.
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