1. Carolien J. W. H. Bruijnen1,2, Susanne Y. Young3, Melanie Bishop3,
Social Anxiety Disorder (SAD) in patients with or without early childhood trauma: Relationship to behavioral inhibition and behavioral activation, and quality of life.
Carolien J. W. H. Bruijnen1,2, Susanne Y. Young3, Melanie Bishop3,
Soraya Seedat3
1.Centre of Excellence for Korsakoff and Alcohol-related Cognitive Disorders, Vincent van Gogh Institute for Psychiatry, Venray, The Netherlands;
2.Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen, Nijmegen, The Netherlands;
3. Department of Psychiatry, Faculty of Medicine and Health Sciences, Tygerberg Campus, Stellenbosch University, Cape Town, 8000, South Africa
Introduction
With a lifetime prevalence of up to 13%, Social Anxiety Disorder (SAD) is the third most common psychiatric disorder in the United States, following depression and alcohol dependence. SAD can be divided into two distinct subtypes: the circumscribed form (CSAD), which is specific for only certain situations; and the more generalized form (GSAD).
Early childhood trauma can have a desensitizing effect on the neural circuits that are under the influence of the corticotrophin-releasing factor (CRF). This neurotransmitter plays a critical role in the regulation of the stress response. Desensitizing the neural circuits leaves a person more vulnerable to stress, depression, and anxiety. Many research topics in the past focused on trying to find a relationship between early childhood trauma and the development of SAD later in life. The present study takes into this account two other factors: anxiety and impulsivity as personality traits and quality of life.
Gray’s Behavioral Inhibition and Behavioral Activation Systems (BIS / BAS):
In his theory, Gray proposes there are two basic dimensions of personality: anxiety and impulsivity. The Behavioral Inhibition System (BIS) is supposed to be sensitive to punishment, non-reward and novel stimuli, activation causes inhibition of goal-directed behavior, which in turn is linked to higher anxiety. The Behavioral Activation System is sensitive to non-punishment, reward, and escape from punishment, and activation causes goal-directed behavior which is linked to higher impulsivity.
Quality of Life:
It can be defined as “the value assigned to the duration of life as modified by the social opportunities, perceptions, functional states, and impairments that are influenced by disease, injuries, treatments, or policies. Measures of Quality of Life can be used to get a sense of the impact of disease on the functioning and well-being of the person.
Materials and Assessment
After obtaining informed consent, each participant was screened for age, gender, educational background, use of any psychotropic medication or other medication, and known medical, neurological and / or psychiatric conditions. After this, all participants were assessed for social anxiety, early childhood trauma, anxiety and impulsivity, quality of life and ethnic social phobia, by filling out five self report questionnaires:
Liebowitz Social Anxiety Scale (LSAS): A scale designed to assess the presence of SAD. The scale consists of 24 items, all answered on a scale of 0 to 3, for both of two components, one fear / anxiety and the other avoidance. To distinguish between SAD and healthy controls, participants scoring 60 or higher were classified as the former, and participants scoring less than 60 were classified as the latter.
Childhood Trauma Questionnaire – Short Form (CTQ-SF): A scale consisting of 28 questions, answered on a five point Likert Scale, assessing five dimensions of childhood maltreatment: physical abuse, emotional abuse, sexual abuse, physical neglect and emotional neglect. Participants with scores between 25 and 40 were categorised as SAD-, and participants with scores between 46 and 125 were categorised as SAD+. The intermediate range serves to make a clear distinction between both groups.
Carver & White’s BIS / BAS Scales: Consisting of 24 items, answered on a four point Likert Scale, this scale is divided in two categories, namely BIS and BAS. The BAS scale is subdivided into three subscales: Drive, Fun Seeking and Reward Responsiveness. It is developed to assess individual differences in the sensitivity of the BIS and BAS systems as described by Gray.
Quality of Life Enjoyment and Satisfaction Questionnaire – Self Report (QLESQ-SR): Consisting of eight categories, this questionnaire is answered on a five point Likert Scale in terms of frequency or satisfaction. The categories are: physical health/activities, feelings, work, household duties, school/course work, leisure time activities, social relations and general activities.
Results
Demographic Data
Data were collected for 102 adults. Criteria for SAD were met by 76 participants, of which 51 participants were exposed to CHT and 25 were not. The remaining 26 participants were demographically matched healthy controls. Measures of anxiety, impulsivity, and QoL were obtained by administering Carver and White’s BIS / BAS Scales and the Quality of Life Enjoyment and Satisfaction Questionnaire – Self Report (QLESQ-SR) respectively.
All participants were between the ages of 20 and 72 years old, with an average age of years (SD = 12.61). On average, participants had years of education (SD = 2.92). Of the participants, 24 were male (44.4%) and 30 were female (55.6%). There were no significant demographic differences among SAD patients with CHT, SAD patients without CHT or healthy controls for age (F2, 99 = 2.49), gender (χ2 = .21), ethnicity (χ2 = 12.57), marital status (χ2 = 5.54), living arrangements (χ2 = 3.85), or employment (χ2 = 1.19). There was however, a significant group difference for education (F2, 99 = 3.96, p < .05). Post hoc tests revealed that healthy controls had significantly more years of education than SAD patients with CHT (M diff = 1.89, p < .05), but there was no difference between healthy controls and SAD patients without CHT (M diff = .53, p > .05) or between SAD patients with or without CHT (M diff = 1.36, p > .05). All of the following analyses were therefore controlled for education.
Clinical Data
SAD and Childhood Trauma
After controlling for years of education, severity of SAD symptoms was significantly correlated with the amount of reported CHT (r = .42, p < .001).
Gray’s Bahavioral Inhibition and Behavioral Activation Systems (BIS / BAS):
Analysis showed a significant effect of group on the total BIS / BAS score was found using Pillai’s trace, V = 0.37, F(4, 102) = 5.69, p < Also when looking separately at the BIS and BAS scores, the main effect was significant. Multiple comparisons revealed a significant difference between the healthy controls and the SAD+ group, and between the healthy controls and the SAD- group, for the BIS scale; and also for the healthy controls and the SAD+ group, and the SAD+ and SAD- groups, for the BAS scale.
Quality of Life:
One way analysis of variance (ANOVA) revealed a significant effect of group on quality of life scores, F(2, 38) = 11.70, p < Post hoc tests revealed a significant difference between the healthy controls and the SAD+ group, and also for the healthy controls and the SAD- group, but not between both SAD groups.
Methods
Aims
The aims of this study are: (1) to explore the possible relationship between the severity of SAD symptoms and childhood trauma suffered during the early years of life, (2) to gain a better understanding of the differences between SAD patients with and those without early childhood trauma, and healthy controls, with regard to anxiety and impulsivity as personality traits, (3) to explore the influences of early childhood trauma on quality of life for patients diagnosed with SAD, compared with healthy controls, and (4) we will correlate between the severity of symptoms, the reported amount of early childhood trauma, the anxiety and impulsivity reported and quality of life.
Conclusion
As becomes clear from the above results, there are many significant differences between healthy controls and SAD patients on all measured factors, regardless of early childhood trauma. Unfortunately, the expected differences between SAD patients with or without early childhood trauma were not found.
Gray’s Behavioral Inhibition and Behavioral Activation Systems (BIS / BADS):
The findings show that healthy controls are more impulsive and less anxious, than both other groups. The expectation that SAD patients without early childhood trauma are more impulsive than SAD patients with early childhood trauma was not found. As for anxiety, no difference between SAD patients with or without early childhood trauma became evident.
Quality of Life:
Looking at the ratings of quality of life, results show that healthy controls score higher in this matter than both SAD groups. However, it was also expected that SAD patients without early childhood trauma rate their quality of life higher than SAD patients with early childhood trauma. Though not significant, the data seem to suggest the opposite: the average quality of life for SAD patients without early childhood trauma is lower than for SAD patients with early childhood trauma. This finding is striking, because it would seem logical that childhood trauma has a detrimental effect on quality of life. However, the seen trend can be explained by the possibility that childhood trauma changes perspective on what is seen as being ‘normal’. If the endured trauma makes you adjust your expectations of life, this could desensitize what is actually the quality of life.
This work is based on the research supported by the South African Research Chairs initiative of the Department of Science and Technology and the National Research Foundation of South Africa