اختلال اضطراب اجتماعی در ارتش چین: شیوع بیماریهای همراه، اختلال و درمان جویی

Abstract The objective of this work is To investigate the prevalence, comorbidities, impairment, and treatment-seeking of social anxiety disorder in the Chinese military personnel. Military personnel (n=11,527) were surveyed from May to August 2007 using a multistage whole cohort probability sampling method. A Chinese version of the World Health Organization Composite International Diagnostic Interview (CIDI) was used for assessment, and a military-related socio-demographic questionnaire was used to describe the prevalence distribution. A unified survey was performed to investigate 11 different social situations. The short-form health survey was used to assess role impairment. The 12-month and lifetime prevalence rates of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. Social anxiety disorder was associated with increased odds of depression, substance abuse, panic attacks/disorder, and generalized anxiety disorder. Childhood foster, female, stressful life events, younger age, and being divorced/widowed increase the incidence of social anxiety disorder. Treatment-seeking was relatively rare. Social anxiety disorder is a common disorder in military personnel in China, and it is a risk factor for subsequent depressive illness, substance abuse and other mental disorder. Early detection and treatment of social anxiety disorder are important because of the low rate of treatment-seeking.

Introduction Social anxiety is pervasive, with a majority of people expressing discomfort in at least one type of social situation (Stein et al., 1994). Investigation of social anxiety disorder in representative civilian showed that social anxiety disorder has a high lifetime prevalence of approximately 5–12% (Kessler and Ustun, 2004, Shields, 2004, Grant et al., 2005, Stein, 2006 and Hsu and Alden, 2007). Social anxiety disorder is associated with increased disability, decreased quality of life, poor role functioning, and suicidal behavior (Stein and Kean, 2000, Wittchen et al., 2000, Wittchen and Fehm, 2001, Simon et al., 2002, Shields, 2004, Ruscio et al., 2008 and Mather et al., 2010). In addition, social anxiety disorder has been shown to be a risk factor for the development of major depression (Stein et al., 2001, Beesdo et al., 2007 and Mather et al., 2010). Recently, a comprehensive examination of the epidemiology and characteristics of social anxiety disorder in a representative sample of active military personnel showed that the military population had characteristics that were similar to the general population (Mather et al., 2010). In the Israeli military, the rate of social phobia was 4.5% (Iancu et al., 2006). Therefore, social anxiety disorder is an extremely important disorder in both general and military populations. Furthermore, the impacts of social anxiety disorders could be exacerbated in military personnel, since they are exposed to situations like adaptation to new places, exposure, discipline, stress associated with ranks and combat situations (Sareen et al., 2007). In China, military service is not compulsory, but the discipline is very strict. Furthermore, the age at enlistment is relatively young, and a large proportion of recruits are from rural areas (Wang et al., 1996). There are few recent reports on the mental health of Chinese military personnel since a mental disorder survey carried in 1994 (Wang et al., 1996). In addition, most studies on the mental health in the military tend to focus on post-traumatic stress disorder (PTSD), depression, and alcohol abuse. In this background, the data about social anxiety disorder are especially rare. Therefore, in the present study, we examined the prevalence of social anxiety disorder and social fears in the military, and determined the sociodemographic correlates and role impairment associated with this disorder. In addition, we tested how social anxiety disorder is related to other mental disorders among military personnel, and examined whether social anxiety disorder interacts with the incidence of other mental disorders. Finally, we determined the frequency of treatment-seeking in military personnel who meet criteria for a diagnosis of social anxiety disorder.

3. Results 3.1. Demographic distribution The mean age of the subjects was 22.0±3.79 years, without significant differences among the different military regions. Most subjects (98.0%) were male. The arm distribution of the final sample was: Land Forces 59.74%, Navy 13.26%, Air Forces 9.06%, Missilery Forces 8.31%, Military Students 4.07%, and Other Forces 5.55%, which was consistent with the general population of the PLA. The final sample properly covered all military regions in China. 3.2. Prevalence For the entire sample, 3.08% of subjects (n=355) met criteria for SAD diagnosis. The twelve-month and lifetime prevalence rates of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. The prevalence of social fears is presented in Table 1. The 12-month prevalence for at least one social fear was 21.2%. The most and least common social fears were “talking to people in authority or a person of a higher status” (18.9%) and “using public washrooms” (7.4%), respectively. Table 1. Prevalence of individual social fears among military personnel. Social fear n(%) SE Talking to people in authority or a person of a higher status 2130 (18.9) 0.41 Performing/giving talk in front of audience 1928 (17.3) 0.40 Talking in a meeting or in class 1727 (15.4) 0.39 Other social/performance situation 1687 (15.2) 0.38 Meeting strangers 1532 (13.6) 0.37 Public performance 1517 (13.5) 0.37 Working, writing, eating, or drinking under others׳ attention 1455 (12.8) 0.36 Entering a room when others are already present 1229 (11.0) 0.34 Talking to unfamiliar others 1200 (10.7) 0.34 Joining gatherings 1097 (9.8) 0.33 Using public washrooms 853 (7.4) 0.29 At least one social fear 2299 (21.2) 0.43 n (%): Number and percentage of respondents with or without social anxiety disorder (lifetime or past-year) who endorsed the given social fear. The ‘n’ was based on the sample, whereas ‘%’ was weighted to be representative of the population of the PLA. Table options As demonstrated in Table 2, social anxiety disorder was associated with a number of sociodemographic variables. The low and intermediate social fear groups were significantly younger and more educated than respondents without any social fear. Childhood foster was significantly related to social anxiety disorder among military personnel. Female was more likely to suffer from social anxiety disorder. Individuals who were separated, widowed, or divorced had a higher likelihood of past-year social anxiety disorder (OR=2.21, 95% CI 1.38–3.31). Officers were less likely than those of junior rank to have either past-year (OR=0.49, 95% CI 0.12–0.85) or lifetime (OR=0.56, 95% CI 0.31–0.89) social anxiety disorder. Table 2. Sociodemographic correlates of lifetime and past-year social anxiety disorder. Socio-demographic variable Lifetime social anxiety disorder OR (95% CI) Past-year social anxiety disorder OR (95% CI) Age – – 18–25 1.00 1.00 26–35 1.41 (1.08–1.96) ⁎ 1.35 (0.98–1.78) 36–45 1.47 (1.15–2.06) ⁎ 1.40 (1.05–1.86) ⁎ 46–55 1.18 (0.88–1.26) 1.09 (0.65–2.25) Sex – – Male 1.00 1.00 Female 1.35 (1.18–1.86) ⁎ 1.68 (1.31–2.27) ⁎ Marital status – – Married/common law 1.00 1.00 Separated/widowed/divorced 1.32 (0.96–1.89) 2.21 (1.38–3.31) ⁎ Single 0.96 (0.58–1.96) 0.94 (0.68–1.53) Education – – Less than high school 1.00 1.00 High school graduate 1.42 (1.11–2.23) ⁎ 1.35 (0.87–1.69) Other post-secondary 1.25 (0.74–1.80) 1.13 (0.56–2.00) Post-secondary graduate 1.05 (0.88–1.33) 0.95 (0.68–1.46) Childhood foster – – Own parents 1.00 1.00 Grandparents 1.52 (1.22–2.86) ⁎ 1.48 (1.15–2.31) ⁎ Other kinfolks 1.55 (1.35–3.25) ⁎ 1.35 (1.10–1.68) ⁎ Rank – – Junior 1.00 1.00 Senior 0.85 (0.75–1.20) 0.73 (0.61–1.06) Officer 0.56 (0.31–0.89) ⁎ 0.49 (0.12–0.85) ⁎ Arm of the service – – Land Forces 1.00 1.00 Navy 0.98 (0.88–1.45) 0.96 (0.76–1.53) Air Forces 1.15 (0.74–2.32) 1.11 (0.86–1.46) Missilery Forces 1.29 (0.96–1.35) 1.21 (0.67–2.01) Military Student 1.32 (1.09–1.66)⁎ 1.30 (1.04–1.85) ⁎ Other Forces 1.24 (0.65–2.95) 1.18 (0.78–1.97) Note: all data were analyzed as mean, S.D.. All odds ratios were unadjusted. 95% CI: 95% confidence interval. ⁎ p<0.05. Table options After adjusting for demographic characteristics and multiple comparisons, we examined the risk of psychiatric disorders associated with the occurrence of social anxiety disorder. As shown in Table 3, military personnel diagnosed with social anxiety disorder were significantly more likely than those without social anxiety disorder to have any lifetime or past-year mental disorder. In respect of lifetime prevalence, the analytic mental disorders (depression, panic attacks, panic disorder, generalized anxiety disorder, and post-traumatic stress disorder) were significantly associated with social anxiety disorder. Similarly, of the past-year disorders, all but alcohol dependence showed significant associations with past-year social anxiety disorder. Table 3. Morbidity of lifetime and past-year social anxiety disorder and other common psychiatric disorders. Diagnosis from CIDI Lifetime social anxiety disorder Past-year social anxiety disorder Psychiatric condition n (%) AOR (95% CI) p n (%) AOR (95% CI) p Depression 201 (31.0) 6.32 (4.87–7.11) <0.001 97 (32.1) 13.52 (9.57–19.63) <0.001 Panic attacks 264 (40.9) 5.17 (4.08–6.58) <0.001 126 (37.0) 10.26 (7.30–15.87) <0.001 Panic disorder 62 (10.4) 4.22 (3.32–5.38) <0.001 48 (14.8) 8.86 (5.07–12.79) <0.001 GAD 109 (16.1) 7.89 (5.99–10.01) <0.001 48 (13.8) 17.36 (11.84–25.34) <0.001 PTSD 100 (15.0) 3.71 (3.01–4.62) <0.001 57 (15.8) 5.88 (3.87–8.47) <0.001 Alcohol dependence 61 (9.5) 2.58 (2.27–3.19) <0.001 23 (6.1) 4.35 (2.13–7.66) <0.001 n (%): Number and percentage of respondents with social anxiety disorder (lifetime or past-year) who also met criteria for the given lifetime or past-year psychiatric disorder. The ‘n’ was based on the sample, whereas the ‘%’ was weighted to be representative of the population. AOR: odds ratio adjusted for age, sex, education, childhood foster care, marital status, and rank. Reference group (AOR=1.00) was respondents without social anxiety disorder. 95% CI: 95% confidence intervals. Table options 3.3. Relation between social anxiety disorder and health-related quality of life We examined the differences in quality-of-life dimensions (SF-36 subscales) between the group with social anxiety disorder and the group without social anxiety disorder. Table 4 shows that the occurrence of social anxiety disorder was associated with poor scores on all dimensions of psychological health (p<0.01). In contrast, no significant correlations were found with physical health indices. Table 4. Relations between social anxiety disorder and quality-of-life dimensions. SF-36 subscales SAD(+), n=355 SAD(−), n=11,172 n=11,172 Test of group differences Role-physical a χ2 (4, 11,523)=33.98 0 141 (39.72%) 3181 (28.47%) p<0.01 1 44 (12.39%) 1732 (15.50%) 2 45 (12.68%) 1977 (17.70%) 3 79 (22.25%) 2039 (18.25%) 4 46 (12.96%) 2243 (20.08%) Role-emotional a χ2 (3, 11,524)=509.73 0 150 (42.25%) 1166 (10.44%) p<0.01 1 75 (21.13%) 983 (8.80%) 2 67 (18.87%) 1326 (11.87%) 3 63 (17.75%) 7697 (68.90%) Social functioning a χ2 (3, 11,524)=211.53 0 100 (28.17%) 1052 (9.42%) p<0.01 1 104 (29.30%) 1854 (16.60%) 2 59 (16.62%) 1967 (17.61%) 3 92 (25.92%) 6299 (56.38%) Mental health b 57.88 (22.3) 83.57 (25.5) p<0.01 Vitality b 47.88 (31.5) 63.26 (39.0) p<0.01 General health b 68.56 (18.9) 80.30 (34.6) p=0.043 Physical functioning b 60.66 (32.5) 88.90 (38.9) p=0.32 a Role-physical (assessing role limitations due to physical health) was on a 0–4 scale. Role-emotional (assessing role limitations due to emotional problems) and social functioning were both on a 0–3 scale. The raw count and percentage of subjects reporting each score are shown. b Continuous raw scores were transformed to a 0–100 scale with means and standard deviations shown. Table options Table 5 shows the patterns of the use of available resources by military personnel with past-year social anxiety disorder. Subjects most frequently reported seeking assistance from psychologists (20.1%). Psychiatrists׳ services were the next most commonly used, with 13.5% of individuals with past-year social anxiety disorder seeking this type of help. Other types of professional services were used less often. Overall, only 25.4% of those with past-year social anxiety disorder sought professional service to deal with mental health problems. The use of other resources, such as internet support groups and telephone help lines, was much less common. Table 5. Use of resources among military personnel with past-year social anxiety disorder. Type of resources % SE Psychiatrist 13.5 1.6 Psychologist 20.1 2.2 Pluralistic counselor 1.2 0.5 General practitioner 0.6 0.2 Telephone helpline 0.8 0.4 Internet support group 1.5 0.9 In total 25.4 4.2 Note: respondents could select more than one resource as having been used in the past year; therefore, percentages are not expected to add up to 100. Note: the ‘n’ value was not presented due to small sizes, which may compromise respondent confidentiality