Literature Review

[page 42] [Mental Illness 2017; 9:7274]

Social anxiety disorder and its impact in undergraduate stu- dents at Jazan University, Saudi Arabia Ramzi M. Hakami,1 Mohamed S. Mahfouz,2 Abdulrahman M. Adawi,1 Adeebah J. Mahha,1 Alaa J. Athathi,1 Hadi H. Daghreeri,1 Hatim H. Najmi,1 Nuha A. Areeshi1 1Faculty of Medicine, Jazan University, Jazan; 2Department of Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia

Abstract Although social anxiety disorder

(SAD) is a common mental disorder, it is often under diagnosed and under treated. The aim of this study is to assess the preva- lence, severity, disability, and quality of life towards SAD among students of Jazan University, Saudi Arabia. A cross-sectional study was conducted among a stratified sample of 500 undergraduate students to identify the prevalence of SAD, its corre- lates, related disability, and its impact on the quality life. All participants completed the Social Phobia Inventory, Leibowitz Social Anxiety Scale, Sheehan Disability Scale, and the WHO Quality of Life – BREF ques- tionnaire. Of 476 students, 25.8% were screened positive for SAD. About 47.2% of the students had mild symptoms, 42.3% had moderate to marked symptoms, and 10.5% had severe to very severe symptoms of SAD. Students who resulted positive for SAD reported significant disabilities in work, social, and family areas, and this has adversely affected their quality of life as compared to those who screened negative for SAD. Students reported several clinical manifestations that affected their function- ing and social life. Acting, performing or giving a talk in front of an audience was the most commonly feared situation. Blushing in front of people was the most commonly avoided situation. Since the present study showed a marked prevalence of SAD among students, increased disability, and impaired quality of life, rigorous efforts are needed for early recognition and treatment of SAD.

Introduction While most of us experience some level

of social unease when we feel scrutinized by others, such as while speaking in public or presenting at meetings, social anxiety disorder (SAD) is defined as an excessive and persistent fear of acting in a way that will be embarrassing and humiliating. This fear is almost invariably provoked by the feared situations, which are avoided or endured with severe distress, and interferes significantly with personal, occupational, and social functioning.1

Social anxiety disorder commonly appears in the teenage years,2 and usually affects 3 to 5% of youths.3 It is an extraor- dinarily persistent condition if left untreated and it may lead to a variety of comorbidi- ties, such as other anxiety disorders, affec- tive disorders, nicotine dependence, and substance-use disorder,4-6 predicting poorer treatment outcomes.7 Most of patients with SAD have been reported to have at least moderate impairment at some point in their lives. Education, employment, family, romantic relationships, friendships, social networks, quality of life, and other areas of life have been reported to be liable to impairment in patients with SAD.8-12 Unfortunately, although it is the third most common mental disorder in adults world- wide,13 SAD is often under diagnosed and undertreated.14 Furthermore, it has received little attention by both clinicians and researchers.8

In general, there is a lack of data on the prevalence of SAD and the reported rates vary widely between studies, with much of the variability possibly being due to differ- ent instruments used to determine diagno- sis.10 However, SAD is obviously one of the most common of all anxiety disorders.10 For instance, Kesseler and colleagues (2005) interviewed 9282 English-speaking partici- pants aged 18 years and older and found that SAD was the most common anxiety disorder, with a lifetime prevalence of up to 12%15 and a 12-month prevalence of 6.8%.16

Studies looking at country-specific pop- ulations of university students have pro- duced quite variable results when it comes to the prevalence of SAD. Many studies have indicated that social anxiety is a preva- lent disorder among university stu- dents.11,12,17-20 For example, studies from Sweden and India have reported the preva- lence of SAD among university students to be 16.1% and 19.5%, respectively.11,12 In the Kingdome of Saudi Arabia, less is known about SAD in general and among undergraduate students. However, high prevalence rates have been reported among

Saudis, especially adolescents and young adults.21-25 Elhadad and colleagues (2017) have carried out a study on 380 medical stu- dents and found that as high as 59.5% of them were screened positive for SAD. In the same study, SAD was associated with decreased academic achievement, weak clinical exam performance, and avoidance of oral presentation.22

The present study aims to investigate SAD prevalence, severity, related disabili- ties, and its impact in students from five faculties at Jazan University, Saudi Arabia. We expect that this study would be helpful in bridging the gap in the local research of SAD, and will be useful to the future studies attempting to reduce the high prevalence of this disorder and to prevent its long-term consequences.

Materials and Methods

Study place, design and participants Jazan University is situated in Jazan

region, southwest of the kingdom of Saudi Arabia. It is the leading higher educational institution in Jazan province. This is an

Mental Illness 2017; volume 9:7274

Correspondence: Ramzi Mohammed Hakami, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia. E-mail: [email protected]

Key words: Mental disorder; social phobia; social anxiety disorder; Saudi Arabia; Social Phobia Inventory.

Acknowledgements: the authors thank Dr. Rashad Alsanosy (Substance Abuse Research Center (SARC), Jazan University and the Department of Family and Community Medicine) for his assistance with the research project.

Contributions: the authors contributed equally.

Conflict of interest: the authors declare no potential conflict of interest.

Received for publication: 20 June 2017. Revision received: 7 August 2017. Accepted for publication: 8 August 2017.

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright R.M.Hakami et al., 2017 Licensee PAGEPress, Italy Mental Illness 2017; 9:7274 doi:10.4081/mi.2017.7274

[Mental Illness 2017; 9:7274] [page 43]

observational cross-sectional survey target- ing Jazan University students who are over 18 years and registered for the academic year 2016/2017. The target colleges were Applied Medical Sciences, Pharmacy, Sciences, Computer sciences and Business administration.

Sample size and sample design A sample of 400 participants was esti-

mated for the purpose of this study. The sample size was calculated using the formu- la for a cross-sectional study, n=[(z2 * p * q)]/d2. Sample size was calculated using the following parameters: p=prevalence of Knowledge 50%, Z=95% confidence inter- val, d=error ≤5%, and a 25% non-response rate. Probability proportional to size sam- pling (PPS) was used to adjust the number of students in each faculty.

Data collection The structured questionnaire was writ-

ten in Arabic and distributed by six medical students to the study population. After explaining the purpose of the study and obtaining verbal consents, data collectors waited somewhere near for the completion of the questionnaire to give the respondents the opportunity to ask clarifying questions regarding the interpretation of terms or items in the questionnaire. All respondents were asked to fill out the survey separately to make sure that they do not duplicate each other’s answers. The data collection process took place in the period from November 2016 to January 2017.

Instruments The questionnaire consisted of demo-

graphic information such as age, sex, facul- ty type, family size, birth order, perceived family income, marital status, and housing type. Rating instruments included the Social Phobia Inventory (SPIN) to detect social anxiety disorder, the Leibowitz Social Anxiety Scale (LSAS) to evaluate social anxiety disorder severity, the Sheehan Disability Scale (SDS) to assess disability due to social anxiety disorder, and the WHO Quality of Life – BREF questionnaire to assess the quality of life. All study tools were translated to simple Arabic by the study authors. The questionnaire took about 15 to 20 minutes to complete.

Social Phobia Inventory The SPIN is a short, self-rating scale

developed by Dr. K.M. Connor to capture the social phobia symptoms.26 It consists of 17 items and each item is rated from 0 (not at all) to 4 (extremely). The scale ranges from 0-68. A score ≥19 suggests social anx-

iety disorder. It has good test-retest reliabil- ity, internal consistency, convergent and divergent validity and can be used for screening of and detecting treatment response to social anxiety disorder. Regarding diagnosis of social anxiety disor- der, it has a sensitivity of 73-85% and a specificity of 69-84%. Although Shah and Kataria12 used a cut-off point of 19 on this scale in a similar study, Dogaheh27 reported that the cut-off point of 29 resulted in bal- anced sensitivity (0.96) and 1-specificity (0.87), and it was more appropriate for this study (a cut-off point of 19 resulted in an oddly very high prevalence).

Liebowitz Social Anxiety Scale The LSAS is self-rating scale developed

by Dr. Michael Liebowitz to rate fear/anxi- ety and avoidance regarding 24 commonly feared performance or social situations.28 It consists of 13 performance-related items and 11 social-related items which are rated from 0 (none/never) to 3 (severe/usually). It has a good internal consistency and evalu- ates the severity of fear and avoidance in common social situations. A score of <55 suggests mild social anxiety disorder, 55-64

suggests moderate social anxiety disorder, 65-79 suggests marked social anxiety disor- der, 80-94 suggests severe social anxiety disorder, and >95 suggests very severe social anxiety disorder.

Sheehan Disability Scale The SDS is a simple and commonly

used scale developed by David V. Sheehan29 to evaluate functional impair- ments/disabilities in the domains of work, social life/leisure and family life/home responsibility due to an anxiety disorder. Each domain is rated on an 11-point, where 0=no impairment, 10=most severe, 1- 3=mild, 4-6=moderate, and 7-9=marked.

WHO Quality of Life – Bref The WHOQOL-BREF is an abbreviated

version of the WHOQOL-100 developed by the WHOQOL Group30 to assess the quality of life in multiple dimensions, and it is applicable cross-culturally. It consists of 26 items based on a four-domain structure: Physical health (7 items), Psychological health (6 items), Social relationships (3 items) and Environment (8 items), along with a self-rating of general quality of life

Article

Table 1. Socio-demographic characteristics of participants.

Characteristics Male, n (%) Female, n (%) Total, n (%) N=243 N=233 N=476

Age in years* 19 – 21 78 (32.1) 161 (70.9) 239 (50.8) 22 – 24 152 (62.6) 64 (28.2) 216 (45.9) 25 – 27 13 (5.3) 2 (0.9) 15 (3.2) College Applied Medical Sciences 44 (18.1) 41 (17.6) 85 (17.9) Pharmacy 14 (5.8) 5 (2.1) 19 (4.0) Business Administration 70 (28.8) 86 (36.9) 156 (32.7) Computer Sciences 59 (24.3) 39 (16.7) 98 (20.6) Sciences 56 (23) 62 (26.6) 118 (24.8)

Marital status* Single 232 (95.9) 192 (83.8) 424 (90.0) Married 8 (3.3) 31 (13.5) 39 (8.3) Divorced 2 (0.8) 6 (2.6) 8 (1.7) Family size* <6 42 (17.3) 33 (14.4) 75 (15.9) 06-10 135 (55.6) 162 (70.7) 297 (62.9) >10 66 (27.2) 34 (14.8) 100 (21.2)

Birth order* First or only child 46 (18.9) 47 (20.5) 93 (19.2) In the middle 159 (65.4) 144 (62.9) 303 (64.1) Last baby 38 (15.6) 38 (16.6) 76 (16.1) Perceived family income (SR/month)* Very good 49 (20.3) 38 (17.4) 87 (19.0) Good 117 (48.5) 98 (45.0) 215 (46.8) Bad 75 (31.1) 82 (37.6) 157 (34.2)

Housing type* Owning housing 191 (78.9) 207 (90.0) 398 (84.3) Rent housing 51 (21.1) 23 (10.0) 74 (15.7) *Because of missing responses, the total percentages do not add up to 100%.

(1 item) and general satisfaction with health (1 item). It is self-administered and each item is scaled from 1-5 in a positive direc- tion, which means that higher scores indi- cate a higher quality of life. Each domain score (mean score of items within that domain) is converted to a scale of 0-100 and indicates an individual’s perception of qual- ity of life in that domain. In the absence of clear cut-off point for such study, a cut-off point of 88.22 (70% of the total scores) was used as suggested by Al-Fayez and Ohaeri31 and Xia et al.32

Statistical analysis The data was analysed using SPSS ver-

sion 20. Descriptive (frequency and per- centage) and inferential statistics (chi- square test) were used to interpret the data. An independent samples t-test was used to analyse the difference between the two groups (students with/without social anxi- ety disorder). Pearson correlation coeffi- cient was used for correlation analysis.

Ethical consideration All participants were informed of their

rights to participate and that their informa- tion would be kept anonymous and only used for the purpose of this study. Ethical approval was obtained from the University Ethical Committee.

Results Of 500 questionnaires, students com-

pleted 476 questionnaires giving a response rate of 95.2%. Table 1 details the sociode- mographic distribution of the study popula- tion. The results show that 243 (51.1%) of respondents were males and 233 (48.9%) were females. The respondents’ age ranged from 19 to 27 years. The mean, median, and mode of students’ age were 21.49, 21, and 22 years, respectively (SD=1.57), which indicates a fairly even distribution of partic- ipants’ ages. The sample consisted of differ- ent faculties with the highest number from Business administration (156, 32.7%) and the lowest number from Pharmacy (19, 4.0%). Most of the respondents (90%) were single (N=424), 8.3% were married (N=39), and 1.7% were divorced (N=8). Those who lived in families consisted of 6-10 members comprised the majority of the study popula- tion (62.9%). Regarding birth order, a high frequency of respondents (303, 64.1%) reported that they were in the middle of their families. Most of the study population perceived their family income as very good (19.0%) and good (46.8%), and lived in their own household (84.3%).

Using a cut-off score of 29, participants were screened positive for social anxiety disorder if they scored 29 or higher on the SPIN scale. Table 2 shows that 123 (25.8%) students were screened positive for SAD, 71 of them (51.1%) were males and 52 were females (42.3%). There was a statistically significant difference in the prevalence of SAD regarding the birth order. Being a first- born child (or the only child) was associated with least prevalence of SAD (15.6%) and being a middle born child was associated with higher prevalence of SAD (61.5%) (X2=6.407, P<0.05). However, with respect to gender, faculty type, family size, per- ceived family income, and housing type, there was no statistically significant differ- ence in the prevalence of SAD (all P values >0.05). In addition, as the range of age groups was narrow, (i.e. most of students were young adults, who are the target popu- lation of this study) and as most of the stu- dents were single, these two parameters (age and marital status) were not signifi- cantly associated (P=0.777 and P=0.511, respectively) with the prevalence of SAD. The Cronbach’s alpha for SPIN scale obtained in this study sample was 0.85.

Using the LSAS scale to detect the severity of SAD, 47.2% (N=58) had mild

symptoms, 42.3%, (N=52) had moderate to marked symptoms, and 10.5% (N=13) had severe to very severe symptoms. As shown in Table 3, the descending ranking of com- monly feared/avoided situations (LSAS scale) was obtained. The most commonly feared situations reported by students were acting, performing or giving a talk in front of an audience (75.0%, N=357), followed by taking a test (74.0%, N=352). The most commonly avoided situations reported by students were blushing in front of people (79.4%, N=377), followed by having to give speeches (76.7%, N=365). The majority of students (76.5%, N=364) reported that being embarrassed or looking stupid is among their worst fears. The Cronbach’s alpha for LSAS scale obtained in this sam- ple was (0.87) and (0.85) for the fear/anxi- ety and avoidance domains, respectively.

An independent samples t-test was employed to compare between students with SAD and students without SAD in their scores on the SDS and QOL scales. As Table 4 shows, the difference between the two groups was statistically significant. Students who screened positive for SAD reported significantly more disabilities in the work (t(474)=6.596, P<0.01), social life (t(473)=6.941, P<0.01), and home areas

Article

Table 2. Comparing social phobia with demographic variables of the participants.

Demographic variables SPIN score <29 SPIN score ≥29 X2 P value n (%) n (%)

Study population 353 (74.2) 123 (25.8) Gender 2.956 0.090 Male 172 (48.7) 71 (57.7) Female 181 (51.3) 52 (42.3)

Age* 0.504 0.777 19 – 21 179 (51.1) 60 (50.0) 22 – 24 161 (46.0) 55 (45.8) 25 – 27 10 (2.9) 5 (4.2) Faculty type 0.225 0.705 Health faculties 79 (22.4) 25 (20.3) Others 274 (77.6) 98 (79.7)

Family size* 0.611 0.737 <6 53 (15.1) 22 (18.0) 06-10 223 (63.7) 74 (60.7) >10 74 (21.1) 26 (21.3) Birth order 6.407 0.041 First or only child 74 (21.1) 19 (15.6) In the middle 228 (65.1) 75 (61.5) Last baby 48 (13.9) 28 (23.0)

Perceived family income (SR/month)* 0.480 0.787 Very good 31 (9.2) 10 (8.3) Good 104 (30.8) 34 (28.1) Bad 203 (60.1) 77 (63.6) Housing type* 1.985 0.192 Owning housing 300 (85.7) 98 (80.3) Rent housing 50 (14.3) 24 (19.7) SPIN, Social Phobia Inventory. *Because of missing responses, total percentages do not add up to 100%.

[page 44] [Mental Illness 2017; 9:7274]

[Mental Illness 2017; 9:7274] [page 45]

(t(474)=4.375, P<0.01). As well, students who screened positive for SAD reported significantly worse quality of life, that is, they scored lower than students who screened negative for SAD on the physical health domain (t(473)=4.220, P<0.01), psy- chological health domain (t(459)=3.970, P<0.01), social relationship domain (t(472)=1.999, P<0.05), and environment domain (t(474)=2.297, P<0.05). The Cronbach’s alpha for SDS scale obtained in this sample was (0.74), and for QOL scale, the Cronbach’s alpha for the respective domains were 0.64 (physical health), 0.64 (psychological health), 0.55 (social rela- tionships), and 0.72 (environment).

As shown in Table 5, both SPIN and LSAS scores were positively correlated with SDS scores. Thus, SAD and its severi- ty were significantly associated with report- ed disabilities in the areas of work, social life, and home life. In contrast, both SPIN and LSAS scores were negatively correlat- ed with QOL score. This means that SAD and its severity were significantly associat- ed with deterioration in all domains of qual- ity of life. In general, these results suggest that students who screened positive for SAD suffered more than students who screened negative from deteriorated func- tioning and quality of life.

Discussion The main purpose of the present study

was to investigate SAD prevalence, severi- ty, related disabilities, and its impact in undergraduate students at Jazan University. SAD symptoms may overlap with other dis- eases making it challenging to recognize and separate SAD from shyness or poor social skills. Many studies of SAD from dif- ferent countries and cultures reported wide- ly varied estimates of the prevalence rang- ing from 1.9% and 20.4% among the gener- al population and depending on the diag- nostic threshold.33 In the present study, SAD was as high as 25.8% among the study population, much higher than many other studies among undergraduate stu- dents.11,12,17,18,34 However, as SPIN, the screening scale used in this study, has a

specificity of 0.84-0.94 and the analysis using LSAS shows that 47.2% of those with SAD have a mild degree of SAD, it can be inferred that the prevalence might be lower than identified. However, the prevalence looks quite high even after this considera- tion. Within the Saudi context, a few studies

have investigated SAD among university students and most of them have been con- ducted on medical students, making it diffi- cult to compare our findings with a similar study. However, consistently with the pres- ent study, social anxiety have been revealed to be a highly prevalent disorder in Saudi

Article

Table 3. Rank ordering of most commonly feared/avoided situations.

Rank Situation N (%) Feared situations

1 Acting, performing or giving a talk in front of an audience 357 (75.0) 2 Taking a test 352 (74.0)

3 Speaking up at a meeting 326 (68.5) 4 Talking to people in authority 299 (62.8)

5 Meeting strangers 289 (60.7) 6 Working while being observed 289 (60.7)

7 Expressing a disagreement or disapproval to people you don’t know very well 284 (59.7) 8 Being the center of attention 275 (46.4)

9 Talking with people you don’t know very well 271 (56.9) 10 Looking at people you don’t know very well in the eyes 267 (56.1)

Avoided situations

1 I am bothered by blushing in front of people 377 (79.4) 2 I avoid having to give speeches 365 (76.7)

3 Being embarrassed or looking stupid is among my worst fears 364 (76.5) 4 Fear of embarrassment causes me to avoid doing things or speaking to people 333 (70.0)

5 I avoid talking to people I don’t know 331 (69.6) 6 I am afraid of doing things when people might be watching 326 (68.5)

7 I would do anything to avoid being criticized 321 (67.5) 8 Trembling or shaking in front of others is distressing to me 318 (66.8)

9 Heart palpitations bother me when I am around people 317 (66.6) 10 I avoid activities in which I am the center of attention 312 (65.6)

Table 4. Disabilities and quality of life in students with social phobia.

SPIN score <29, SPIN score ≥29, t P value M (SD) M (SD)

Disabilities Work 0.79 (0.885) 1.42 (0.984) 6.596 0.000 Social life 0.73 (0.846) 1.38 (1.028) 6.941 0.000 Home 0.81 (1.047) 1.30 (1.116) 4.375 0.000 Quality of life Physical health 64.92 (15.641) 58.11 (14.585) 4.220 0.000 Psychological health 72.23 (16.206) 65.25 (17.195) 3.970 0.000 Social relationships 67.13 (21.272) 62.50 (24.136) 1.999 0.046 Environment 63.01 (16.492) 59.08 (15.769) 2.297 0.022 SPIN, Social Phobia Inventory

Table 5. Correlating SPIN and LSAS with SDS and QOL scores.

SDS score QOL score Work Social life Home Physical health Psychological health Social relationship Environment

SPIN score (r) 0.29** 0.30** 0.19** -0.19** -0.18**-0.92* -0.11* LSAS score (r) 0.29** 0.26** 0.26** -0.20** -0.13**-0.11* -0.19** SPIN, Social Phobia Inventory; LSAS, Leibowitz Social Anxiety Scale; SDS, Sheehan Disability Scale; QOL, WHO Quality Of Life – Bref. r is Pearson correlation coefficient. *P<0.01. **P<0.05.

[page 46] [Mental Illness 2017; 9:7274]

undergraduate students population.22,23 Regarding socio-demographic features,

this study found no significant age or gen- der differences among students with SAD. In terms of age, student ages were overall similar as a product of the sample popula- tion, and thus age was not studied as a vari- able compared to other cohorts of the gener- al population, though other studies have shown an early onset of social anxiety symptoms.2,35 In terms of gender, our study’s finding of no difference is overall in line with the body of research that has yield- ed inconclusive comparisons of gender prevalence of SAD.36 Some studies focus- ing on students have found a higher preva- lence among male students and suggested a culturally-specific emphasis placed on males for social tasks,25 but more research into these gender differences is certainly warranted. Consistently with Australian, Indian and Swedish studies, this study reported that SAD was more prevalent among students of Business Administration, Sciences and Computer Sciences (i.e. non- medical faculties) than students of Applied Medical Sciences and Pharmacy (i.e. med- ical faculties).11,12,37 Although SAD is expected to be higher among students of higher-pressure faculties like medical sci- ences and pharmacy, less prevalent SAD can be explained by considering that med- ical faculties are competitive and require high academic and social skills.12

The most commonly reported feared sit- uations in the target sample were Acting, performing or giving a talk in front of an audience followed by Taking a test, and the most commonly avoided situations were Blushing in front of people followed by Having to give speeches. These findings are consistent with that of earlier studies.11-13 It is noteworthy that university students face these situations daily. Elhadad et al. report- ed that students with SAD were more likely to have a weak clinical exam performance, and to avoid performing oral presenta- tions.22 In addition, the analysis of LSAS showed that the majority of students had mild to moderate forms of SAD, which is in accordance with prior studies on university students.11,12 If untreated, SAD may affect the academic future of students and lead to several comorbidities, including other anxi- ety disorders, depression and bipolar disor- ders, and substance abuse.4-6

In the present study, it was found that SAD is associated with impairment in the area of work, social life, and family life. This finding is supported by prior studies on SAD among students, which reported more disabilities among people with SAD.8-12 Also, consistently with previous stud- ies,12,25,38-40 we found that those with SAD

showed a significant reduction in all areas of quality of life, including physical and psychological health, social relationships, and environment. In the present study, stu- dents with SAD were more likely than stu- dents without SAD to be unsatisfied with their health, suffer from depression and psy- chological distress, rate their quality of life as poor, and to be unsatisfied with many aspects of life.12 For example, 20.5% of stu- dents with SAD reported dissatisfaction with their sleep and daily activities, and 22.9% reported dissatisfaction with their sexual life.

In sum, this study confirms the high prevalence of SAD among undergraduate students and its substantial impact on them, and provides a connection between prior studies of certain populations of university students and those at Jazan University. It can also serve as a model for other universi- ty-specific investigations, as well as certain geographic or demographic groups.

Study limitations This study targeted only university stu-

dents and it is necessary to choose a com- munity representative sample to generalize the results. This is a self-report cross-sec- tional study, and a longitudinal study using structured clinical interview is needed to assess SAD among students. Social desir- ability bias is inevitable in such studies as social anxiety is by nature a sensitive issue.

Conclusions SAD has a quiet high prevalence and

marked impact on the quality of life of uni- versity students. These findings necessitate more hard efforts in recognizing and treat- ing SAD in the academic constitutions. Early detection and appropriate treatment will help in reducing the bad consequences of this common disorder.

References 1. American Psychiatric Association.

Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013.

2. Davidson JR, Hughes DL, George LK, Blazer DG. The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area Study. Psychol Med 1993;23:709-18.

3. Wittchen HU, Stein MB, Kessler RC. Social fears and social phobia in a com- munity sample of adolescents and young adults: prevalence, risk factors

and co-morbidity. Psychol Med 1999;29:309-23.

4. Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety dis- order in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2005;66:1351-61.

5. Fehm L, Beesdo K, Jacobi F, Fiedler A. Social anxiety disorder above and below the diagnostic threshold: preva- lence, comorbidity and impairment in the general population. Soc Psychiatry Psychiatr Epidemiol 2008;43:257-65.

6. Sadock BJ, Sadock VA. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition. NewYork: Lippincott Williams & Wilkins; 2007.

7. Fava M, Rush AJ, Alpert JE, et al. Difference in treatment outcome in out- patients with anxious versus nonanx- ious depression: a STAR*D report. Am J Psychiatry 2008;165:342-51.

8. Connor KM, Davidson JRT, Sutherland S, Weisler R. Social phobia: issues in assessment and management. Epilepsia 1999;40:60-5.

9. Timothy J, Atezaz S. Social anxiety dis- order: a common unrecognized mental disorder. Am Fam Physician 1999;60: 2311-9.

10. National Institute for Health Excellence and Care. Social Anxiety Disorder - the Nice Guideline on Recognition, Assessment and Treatment. 2013. 320 p.

11. Tillfors M, Furmark T. Social phobia in Swedish university students: preva- lence, subgroups and avoidant behavior. Soc Psychiatry Psychiatr Epidemiol 2007;42:79-86.

12. Shah PS, Kataria L. Social phobia and its impact in Indian university students. Internet J Ment Health 2010;6:1-8.

13. Veale D. Treatment of social phobia. Adv Psychiatr Treat 2003;9:258-64.

14. Priyamvada R, Kumari S, Prakash J, Chaudhury S. Cognitive behavioral therapy in the treatment of social pho- bia. Ind Psychiatry J 2009;18:60-3.

15. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of- onset distributions of DSM-IV disor- ders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.

16. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:617.

17. Gültekin B, Dereboy I. The prevalence

Article

[Mental Illness 2017; 9:7274] [page 47]

of social phobia, and its impact on qual- ity of life, academic achievement, and identity formation in university stu- dents. Turk Psikiyatr Derg 2011;22:150-8.

18. Izgic F, Akyuz G, Dogan O, Kugu N. Social phobia among university stu- dents and its relation to self-esteem and body image. Can J Psychiatry 2004;49: 630-4.

19. Bella T, Omigbodun O. Social phobia in Nigerian university students: preva- lence, correlates and co-morbidity. Soc Psychiatry Psychiatr Epidemiol 2009; 44:458-63.

20. Baptista CA, Loureiro SR, De Lima Osorio F, et al. Social phobia in Brazilian university students: Prevalence, under-recognition and aca- demic impairment in women. J Affect Disord 2012;136:857-61.

21. Al-Qahtani ALIM. Prevalence and risk factors of social phobia among second- ary school male students in Khamis Mushayt, Kingdom of Saudi Arabia. Med J Cairo Univ 2012;80:871-6.

22. Elhadad AA, Alzaala MA, Alghamdi RS, et al. Social phobia among Saudi medical students. Middle East Curr Psychiatry 2017;24:68-71.

23. Jarallah H, Al-Omari F, Altowairiqi I, Al Saadi K. Magnitude of social anxiety disorder, and impact on quality of life among medical students, taif city-KSA. J Psychol Clin Psychiatry 2017;7.

24. Ghazwani JY, Khalil SN, Ahmed RA.

Social anxiety disorder in Saudi adoles- cent boys: Prevalence, subtypes, and parenting style as a risk factor. J Fam Community Med 2016;23:25-31.

25. Alkhathami S, Kaviani H, Emma S. Social anxiety among adolescents and its relation to quality of life. Eur Proc Soc Behav Sci 2014;218:228.

26. Connor KM, Davidson JRT, Churchill LE, et al. Psychometric properties of the social phobia inventory (SPIN). Br J Psychiatry 2000;176:379-86.

27. Dogaheh ER. Psychometric Properties of Farsi Version of the Social Phobia Inventory (SPIN). Proc Soc Behav Sci 2013;84:763-8.

28. Liebowitz M. Social phobia. Mod Probl Pharmacopsychiatry 1987;22:141-73.

29. Sheehan DV. The anxiety disease. New York: Scribner; 1983.

30. Whoqol group. Development of the World Health Organization WHOQOL- BREF quality of life assessment. Med Psychol 1998;28:551-8.

31. Al-Fayez GA, Ohaeri JU. Profile of subjective quality of life and its corre- lates in a nation-wide sample of high school students in an Arab setting using the WHOQOL-Bref. BMC Psychiatry 2011;11:71.

32. Xia P, Li N, Hau KT, et al. Quality of life of Chinese urban community resi- dents: a psychometric study of the mainland Chinese version of the WHO- QOL-BREF. 2012;

33. Furmark T, Tillfors M, Everz P, et al.

Social phobia in the general population: prevalence and sociodemographic pro- file. Soc Psychiatry Psychiatr Epidemiol 1999;34:416-24.

34. Bella TT, Omigbodun OO. Social pho- bia in Nigerian university students: prevalence, correlates and co-morbidity. Soc Psychiatry Psychiatr Epidemiol 2009;44:458-63.

35. de Menezes GB, Fontenelle LF, Versiani M. Trans-cultural aspects of social anxiety disorder and related con- ditions: a Brazilian case series and a review of international clinical studies. J Braz Psiquiatr 2006;55:196-200.

36. Asher M, Asnaani A, Aderka IM. Gender differences in social anxiety disorder: a review. Clin Psychol Rev 2017;56:1-12.

37. Wilson IG. Screening for social anxiety disorder in first year university stu- dents: a pilot study. Aust Fam Physician 2005;34.

38. El-tantawy AM, Raya YM, Al-Yahya AH, Zaki AMK. Social phobia among patients attending the outpatient clinics of Buraydah Mental Health Hospital, Al-Gassim, KSA. Curr Psychiatry 2010;20-2.

39. Stein MB, Kean YM. Disability and quality of life in social phobia: epidemi- ologic findings. Am J Psychiatry 2000;157:1606-13.

40. Wittchen H, Beloch E. The impact of social phobia on quality of life. Int Clin Psychopharmacol 1996;11:15-23.

Article