اختلال اضطراب اجتماعی و قربانی شدن در یک نمونه جامعه از نوجوانان

Abstract Despite high prevalence rates of social anxiety disorder (SAD) and high rates of victimization in adolescents, studies on the relationship between these phenomena are missing. In the present study we report associations between SAD and multiple victimization experiences in a community sample of adolescents. A cross-sectional study was conducted on 3211 Swedish high-school students. The prevalence rate of self-reported SAD was 10.6% (n = 340). Significantly higher rates of lifetime victimization was found in subjects with self-reported SAD compared to non-cases, on the total score on the Juvenile Victimization Questionnaire, and on the subscales maltreatment, sexual victimization and victimization from peer/siblings. Different results emerged due to gender. In females, maltreatment and peer/sibling victimization was associated with an increased risk of SAD and, in males peer/sibling victimization increased the risk of reporting SAD. Further studies are needed to elaborate developmental models on SAD and to add to modification of prevention- and treatment interventions.

Introduction Social anxiety disorder (SAD) is characterized by an excessive fear of negative evaluation in situations of social interaction or performance, leading to avoidance, distress and impairment (American Psychiatric Association, 1994). Lifetime prevalence rates of SAD in children and adolescents range from 1.6% to 13.3% (Essau et al., 1999, Gren-Landell et al., 2009, Kessler et al., 1994 and Wittchen et al., 1999). Typical onset occurs in early- to midadolescence (Fehm, Pelissolo, Furmark, & Wittchen, 2005). A multifactorial aetiology involving genetic and environmental factors has been proposed, though a complete model on what constitutes risk factors and how these interact is missing (Rapee & Spence, 2004). Traumatic or otherwise negative life events have been suggested as contributing risk factors (Ollendick & Hirshfeld-Becker, 2002). Theoretical models of conditioning offer one way of understanding the contribution of negative life events to the development of SAD. According to this model, SAD can result from humiliating interpersonal situations via a biological preparedness to react to social threat cues (Rapee and Spence, 2004 and Stemberger et al., 1995). From the view of interpersonal theories, SAD can be conceptualized as an interpersonal disorder that develops as a result of early noxious experiences in the interaction with others (Alden & Taylor, 2004). In short, it is postulated that early relationships shape a sense of self and what to expect from others, which build up cognitive structures and relational schemas, that are activated in future relations. Thus, for example, an interpersonal event like peer victimization could be of particular interest in studies on the etiology of SAD. Support for a significant association between peer victimization and SAD has been found, with higher rates of social anxiety or SAD in peer victimized children and adolescents (Ranta, Pelkonen, et al., 2009, Siegel et al., 2009, Storch and Ledley, 2005 and Vernberg et al., 1992). Other than studies on peer victimization and SAD, the main support for an association between SAD and traumatic or negative life events in childhood stems from retrospective studies and cross-sectional studies on adult samples (Bandelow et al., 2004, Chartier et al., 2001, Magee, 1999, Marteinsdottir et al., 2007, Nelson et al., 2002 and Stein et al., 1996). In the study of Chartier et al. (2001), with participants aged 15–64, increased risk of SAD was seen in subjects with a range of childhood aversive experiences including severe childhood sexual abuse and severe childhood physical abuse. Gender has been proposed as a moderator on general psychiatric effects of childhood victimization (Gershon, Minor, & Hayward, 2008). In adults, sexual abuse in childhood and an increased risk of SAD in females has been reported (Boudreaux et al., 1998, Dinwiddie et al., 2000, Magee, 1999 and Molnar et al., 2001). However, so far studies on gender differences relating to social anxiety and victimization in children and adolescents have mainly concerned peer victimization. Results are inconsistent, with some showing higher rates of social anxiety in peer victimized adolescent males (Flanagan, Erath, & Bierman, 2008), while others have reported peer victimization to predict depression and anxiety in bullied females but not in males (Bond, Carlin, Thomas, Rubin, & Patton, 2001). Yet others show no or minor gender differences (La Greca and Harrison, 2005 and Siegel et al., 2009). In studies on the psychological effects of trauma, there is growing support for studying multiple exposures to trauma instead of single exposure (Allen et al., 2008, Finkelhor et al., 2007, Kessler et al., 1997, Suliman et al., 2009 and Turner et al., 2006). Prognosis after a first trauma exposure is generally favourable (Copeland, Keeler, Angold, & Costello, 2007), but one traumatic event is often followed by multiple experiences and different types of victimization (Finkelhor et al., 2005 and Goodyer, 1994). Studies on the relation of multiple victimization (polyvictimization) and symptoms of anxiety are inconsistent, where some studies report an association with higher levels of anxiety in children and adolescents (Copeland et al., 2007 and Singer et al., 1995) and in adults (Cortes et al., 2005 and Safren et al., 2002). However, another study did not find a cumulative effect of victimization on symptoms of anxiety though childhood trauma significantly contributed to anxiety symptoms (Suliman et al., 2009). To our knowledge there are no studies on SAD and multiple victimizations in children and adolescents. Sociodemographic variables are strongly associated with exposure of victimization (Turner et al., 2006). There are, on the other hand, few and inconsistent findings on sociodemographic variables in children and adolescents with SAD (Kearney, 2005) except a strong support for a female preponderance (Gren-Landell et al., 2009 and Kessler et al., 1994). Lower socio-economic status in families of boys with SAD has been reported (Tiet et al., 2001). Ethnicity variables have been found to influence anxiety disorders (Angold et al., 2002) though this has not been reported in adolescents with SAD.

Conclusions and future studies Experiences of victimization and conditions of SAD are common in older Swedish adolescents and especially, there is an association between SAD and maltreatment, peer victimization and in girls also with sexual victimization. The results need to be extended in longitudinal studies on interpersonal victimization and SAD for further elaboration on developmental models on SAD and to add to modifications of prevention- and treatment interventions. Most important in the understanding of SAD, is the mutual interaction of individual and environmental factors but no elaboration of different risk factors was conducted in the present study. In order to receive a better understanding of the development of SAD, it is required that studies include a range of risk factors and that comparisons of different outcomes are made.