Social anxiety disorder (SAD) is characterized by fear of embarrassing oneself in social or performance situations. Subjects with generalized SAD fear several different social situations. SAD is a particularly prevalent and disabling anxiety disorder [59,60]. Thus, subjects with SAD are more likely to be single, are less likely to complete high school or tertiary studies, and are more likely to be unemployed and receive a lower income . It seems reasonable to argue that early intervention for SAD, even in childhood and adolescence, may prevent the negative impact of this disorder. Long-term studies are, however, needed in this area.
SAD has a relatively early onset, and can persist for many years. Comorbid disorders often begin later on . These include major depression, other anxiety disorders and substance use disorders. Simple screening questions  or scales, such as the Liebowitz Social Anxiety Scale (LSAS) and the Mini-Social Phobia Inventory (SPIN), are useful for screening for the presence of the disorder [63,64]. However, given that many people with SAD are unaware that they have a treatable medical disorder, and do not present to physicians for care, it is also important to increase awareness of the condition in the community as a whole. Early robust treatment of SAD might conceivably be able to decrease the morbidity of this condition, and prevent secondary comorbidity.
Although anxiety disorders demonstrate relatively high heritability , clinical entities are relatively heterogeneous, and there is growing interest in endophenotypes that may be more directly linked to genetic variants. Behavioural inhibition (BI) to the unfamiliar, for example, may be an endophenotype of particular relevance to SAD. Seen in around 20% of young children, it is defined by a stable tendency to be behaviourally restrained in unfamiliar social and non-social situations . A number of similar temperamental styles have been described by other authors .
BI has specific biological correlates , including an association with the allele of the corticotropin releasing hormone (CRH)-linked locus , and increased amygdala response to novel stimuli in adulthood . BI is a risk factor for the subsequent development of anxiety disorders, particularly SAD and panic disorder [71,72]. Withdrawn temperament is a strong predictor of childhood anxiety disorders, a reasonable predictor of adolescent anxiety disorders, and a weak to moderate predictor of adult anxiety disorders . Furthermore, by adolescence early inhibition predicts not only anxiety but also depression, and by adulthood it may predict an even broader range of disorders .
An immediate question is whether early identification of children with BI and appropriate interventions are helpful in preventing adult anxiety disorders. There are preliminary data in the affirmative. Inhibited children, aged 3.5 to 4.5 years of age, were recruited to an intervention study via questionnaires distributed to preschools. Interventions were conducted with parents only, with the main aim of providing techniques that help children become more confident and outgoing. Early data from the study of 120 inhibited children suggested that subjects in the intervention group showed a markedly greater reduction in the number of anxiety diagnoses at 12 months relative to controls .
A range of other potentially modifiable risks for SAD and anxiety disorders include parental expression of anxiety, parental overprotection and modelling of anxious responses . These factors may further contribute to the development of BI, or may be independent risk factors. Nevertheless, it is notable that most children with BI do not develop anxiety disorders. Therefore it is also important to consider protective factors, such as social support and coping skills. Particular kinds of parental interventions may be able to ensure that BI does not translate into later psychopathology. Ultimately, work delineating the risk and protective factors for anxiety disorders may well lead to novel interventions to prevent the onset of these conditions .
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