Detection of social anxiety disorder in older adults may be challenging because of sev- eral factors, including a focus on somatic symptoms, comorbid medical illness, limited insight, changes to social environment or roles that may obscure impairment in social functioning, or reticence about describing psychological distress.
Temperamental. Underlying traits that predispose individuals to social anxiety disor- der include behavioral inhibition and fear of negative evaluation.
Environmental. There is no causative role of increased rates of childhood maltreatment or other early—onset psychosocial adversity in the development of social anxiety disorder. How- ever, childhood maltreatment and adversity are risk factors for social anxiety disorder.
Genetic and physiological. Traits predisposing individuals to social anxiety disorder, such as behavioral inhibition, are strongly genetically inﬂuenced. The genetic inﬂuence is subject to gene-environment interaction; that is, children with high behavioral inhibition are more susceptible to environmental inﬂuences, such as socially anxious modeling by parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so).
First—degree relatives have a two to six times greater chance of having social anxiety dis- order, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.
The syndrome of taijin kyofusho (e.g., in Japan and Korea) is often characterized by social- evaluative concerns, fulfilling criteria for social anxiety disorder, that are associated with the fear that the individual makes other people uncomfortable (e.g., "My gaze upsets peo- ple so they look away and avoid me”), a fear that is at times experienced with delusional intensity. This symptom may also be found in non-Asian settings. Other presentations of taijin kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder.
Immigrant status is associated with significantly lower rates of social anxiety disorder in both Latino and non—Latino white groups. Prevalence rates of social anxiety disorder may not be in line with self—reported social anxiety levels in the same culture—that is, societies with strong collectivistic orientations may report high levels of social anxiety but low prev- alence of social anxiety disorder.
Females with social anxiety disorder report a greater number of social fears and comorbid depressive, bipolar, and anxiety disorders, whereas males are more likely to fear dating, have oppositional defiant disorder or conduct disorder, and use alcohol and illicit drugs to relieve symptoms of the disorder. Paruresis is more common in males.
Functional Consequences of Social Anxiety Disorder
Social anxiety disorder is associated with elevated rates of school dropout and with de- creased well-being, employment, workplace productivity, socioeconomic status, and quality of life. Social anxiety disorder is also associated with being single, unmarried, or divorced and with not having children, particularly among men. In older adults, there may be impair- ment in caregiving duties and volunteer activities. Social anxiety disorder also impedes lei- sure activities. Despite the extent of distress and social impairment associated with social anxiety disorder, only about half of individuals with the disorder in Western societies ever seek treatment, and they tend to do so only after 15—20 years of experiencing symptoms. Not being employed is a strong predictor for the persistence of social anxiety disorder.