Psychiatry Research 220 (2014) 903–908

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Social anxiety disorder in the Chinese military: Prevalence,

comorbidities, impairment, and treatment-seeking
Huaning Wang a,1, Ruiguo Zhang a,1, Yunchun Chen a, Huaihai Wang a, Yahong Zhang a,
Jingli Gan b, Liyi Zhang c, Qingrong Tan a,n
a
Department of Psychiatry, Xijing Hospital, The Fourth Military Medical University, No. 15 Changle Road, Xi'an 710032, China
b
Department of Psychiatry, 91 Hospital of People's Liberation Army, No. 239 Gongye Road, Jiao'zuo 454003, China
c
Department of Psychiatry, 102 Hospital of People's Liberation Army, No. 55 Heping Road, Chang'zhou 213003, China

art ic l e i nf o a b s t r a c t

Article history: The objective of this work is To investigate the prevalence, comorbidities, impairment, and treatment-
Received 17 June 2013 seeking of social anxiety disorder in the Chinese military personnel. Military personnel (n¼ 11,527) were
Received in revised form surveyed from May to August 2007 using a multistage whole cohort probability sampling method. A Chinese
25 February 2014
version of the World Health Organization Composite International Diagnostic Interview (CIDI) was used for
Accepted 27 July 2014
Available online 1 August 2014
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
Keywords: health survey was used to assess role impairment. The 12-month and lifetime prevalence rates of social
Social anxiety disorders anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. Social anxiety
Chinese military personnel
disorder was associated with increased odds of depression, substance abuse, panic attacks/disorder, and
Epidemiology
generalized anxiety disorder. Childhood foster, female, stressful life events, younger age, and being divorced/
Comorbidity
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.
& 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction personnel showed that the military population had characteristics

that were similar to the general population (Mather et al., 2010). In
Social anxiety is pervasive, with a majority of people expressing the Israeli military, the rate of social phobia was 4.5% (Iancu et al.,
discomfort in at least one type of social situation (Stein et al., 1994). 2006). Therefore, social anxiety disorder is an extremely important
Investigation of social anxiety disorder in representative civilian disorder in both general and military populations. Furthermore, the
showed that social anxiety disorder has a high lifetime prevalence impacts of social anxiety disorders could be exacerbated in military
of approximately 5–12% (Kessler and Ustun, 2004; Shields, 2004; personnel, since they are exposed to situations like adaptation to
Grant et al., 2005; Stein, 2006; Hsu and Alden, 2007). Social anxiety new places, exposure, discipline, stress associated with ranks and
disorder is associated with increased disability, decreased quality of combat situations (Sareen et al., 2007). In China, military service is
life, poor role functioning, and suicidal behavior (Stein and Kean, not compulsory, but the discipline is very strict. Furthermore, the
2000; Wittchen et al., 2000; Wittchen and Fehm, 2001; Simon age at enlistment is relatively young, and a large proportion of
et al., 2002; Shields, 2004; Ruscio et al., 2008; Mather et al., 2010). recruits are from rural areas (Wang et al., 1996).
In addition, social anxiety disorder has been shown to be a risk There are few recent reports on the mental health of Chinese
factor for the development of major depression (Stein et al., 2001; military personnel since a mental disorder survey carried in 1994
Beesdo et al., 2007;Mather et al., 2010). Recently, a comprehensive (Wang et al., 1996). In addition, most studies on the mental health
examination of the epidemiology and characteristics of social in the military tend to focus on post-traumatic stress disorder
anxiety disorder in a representative sample of active military (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
n
of social anxiety disorder and social fears in the military, and
Corresponding author. Tel.: þ 86 13609161341; fax: þ 86 29 83293951.
E-mail address: [email protected] (Q. Tan).
determined the sociodemographic correlates and role impairment
1
Co-first authors. associated with this disorder. In addition, we tested how social

http://dx.doi.org/10.1016/j.psychres.2014.07.063
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.
904 H. Wang et al. / Psychiatry Research 220 (2014) 903–908

anxiety disorder is related to other mental disorders among information was collected regarding the types of services used. This information
was used to characterize whether military personnel with social anxiety disorder
military personnel, and examined whether social anxiety disorder
seek help for their social fears and, if so, what types of help are sought.
interacts with the incidence of other mental disorders. Finally, we
determined the frequency of treatment-seeking in military per-
sonnel who meet criteria for a diagnosis of social anxiety disorder. 2.4. Analysis methods

2. Methods Data were reported as prevalence and 95% confidence interval (95% CI). Military
Region and Army Services cross-tabulations were used to determine the prevalence
of social anxiety disorder and social fears, comorbidities, role impairment, and
2.1. Subjects treatment-seeking. Standard errors were estimated using the Taylor series linear-
ization method (Wolter, 1985) implemented in the SAS8.2 software (SAS Institute,
Surveyed subjects included active soldiers in service, officers ranked below Cary, NY, USA) to adjust for the clustering and weighting of data. The stepwise
lieutenant, and students in military universities, all among the Land Forces, Navy, logistic regression model method was used to examine the odds of meeting criteria
Air Forces and Missilery Forces of the People Liberation Army (PLA) in China. for social anxiety disorder among the various social fear categories, the relationship
between number of social fears and likelihood of mental disorder comorbidities,
2.2. Sampling and the sociodemographic correlates of social anxiety disorder. Statistical signifi-
cance was based on two-sided tests evaluated at a 0.05 level of significance.

The survey was based on a multistage clustered area probability sampling that
involved personnel in the seven military regions of the PLA and different Army
Services (Navy, Air Forces, Missilery Forces, Military Students, and Other Forces).
The target sample was 14,000, and the final number of responses was 11,527 3. Results
(82.33%). Additional factors were used to adjust for differential probabilities to
match the samples to military region and Army Services distributions. 3.1. Demographic distribution

2.3. Measures The mean age of the subjects was 22.0 73.79 years, without
significant differences among the different military regions. Most
2.3.1. Psychiatric diagnoses
subjects (98.0%) were male. The arm distribution of the final
The WHO Composite International Diagnostic Interview (CIDI 3.0), a fully
structured diagnostic interview, was used for psychiatric diagnosis (Kessler and
sample was: Land Forces 59.74%, Navy 13.26%, Air Forces 9.06%,
Ustun, 2004; Kessler et al., 2005). Both the International Classification of Diseases Missilery Forces 8.31%, Military Students 4.07%, and Other Forces
(ICD-10) (Demyttenaere et al., 2004) and Diagnostic and Statistical Manual 5.55%, which was consistent with the general population of the
(DSM-IV) (1994) diagnoses were examined; DSM-IV diagnoses were used in the PLA. The final sample properly covered all military regions in
present study. A military-related sociodemographic questionnaire was used to
China.
describe the prevalence distribution and to estimate the risk factors in the PLA.
The CIDI was translated into Chinese and back-translated using a standard
WHO protocol. An expert panel composed of three academic psychiatrists with
epidemiological expertise and a survey methodologist from the Research Center for 3.2. Prevalence
Contemporary China (Beijing, China) evaluated its content validity, tested it with
Chinese patients, and revised it to ensure that the Chinese terms used were easily
understood by lay interviewers. All interviewers were trained at the Fourth Military
For the entire sample, 3.08% of subjects (n ¼355) met criteria
Medical University (Xi'an, China). for SAD diagnosis. The twelve-month and lifetime prevalence rates
of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and
2.3.2. Social fears 6.22% (95% CI: 6.11–6.32%), respectively. The prevalence of social
Eleven different social situations were investigated using a previously fears is presented in Table 1. The 12-month prevalence for at least
described method (Lee et al., 2009; Mather et al., 2010). Briefly, a unified survey one social fear was 21.2%. The most and least common social fears
was performed to investigate whether the respondents had ever felt shy, uncom-
were “talking to people in authority or a person of a higher status”
fortable, or afraid in any of 11 different social situations (such as meeting new
people, working while someone was watching, using public washrooms, etc.). Two (18.9%) and “using public washrooms” (7.4%), respectively.
qualitative and quantitative variables were created to analyze the associations As demonstrated in Table 2, social anxiety disorder was
between the number of social fears and a variety of outcomes, such as mental associated with a number of sociodemographic variables. The
disorder comorbidities.
low and intermediate social fear groups were significantly younger
and more educated than respondents without any social fear.
2.3.3. Role impairment
Childhood foster was significantly related to social anxiety dis-
The short-form health survey (SF-36) (Ware and Sherbourne, 1992; Ware, 1997)
was used to assess role impairment. Respondents who endorsed at least one social order among military personnel. Female was more likely to suffer
fear were asked to which extent their health domains (physical functioning; social from social anxiety disorder. Individuals who were separated,
functioning; daily role limitations) were impaired in the past year by their fear or widowed, or divorced had a higher likelihood of past-year social
avoidance. For all subscales, higher scores reflected better mental health. The SF-36
anxiety disorder (OR ¼2.21, 95% CI 1.38–3.31). Officers were less
raw scores for physical functioning, vitality, mental health, and general health were
transformed into a 0–100 scale (according to scoring and formulas in the SF-36
likely than those of junior rank to have either past-year (OR ¼0.49,
Health Survey Manual) (Ware, 1997). Due to non-normal distributions, 3 subscales 95% CI 0.12–0.85) or lifetime (OR ¼0.56, 95% CI 0.31–0.89) social
were transformed into categorical variables based on response distributions (i.e., anxiety disorder.
role-physical on a 0–4 scale; social functioning and role-emotional on a 0–3 scale). After adjusting for demographic characteristics and multiple
comparisons, we examined the risk of psychiatric disorders
2.3.4. Sociodemographic variables associated with the occurrence of social anxiety disorder. As
A number of sociodemographic variables were examined to determine their
association with social anxiety disorder and particular social fears. Specifically, age,
shown in Table 3, military personnel diagnosed with social anxiety
gender, childhood foster (real parents vs. foster parents), trauma history during disorder were significantly more likely than those without social
duty (negative vs. positive), rank (soldier, petty officer and officer), education, anxiety disorder to have any lifetime or past-year mental disorder.
military rank, and arm of the service were included. In respect of lifetime prevalence, the analytic mental disorders
(depression, panic attacks, panic disorder, generalized anxiety
2.3.5. Treatment-seeking disorder, and post-traumatic stress disorder) were significantly
Respondents who endorsed at least one social fear were asked whether they had
ever received professional help for their social fears. All respondents were also asked
associated with social anxiety disorder. Similarly, of the past-year
whether they had sought help for problems with their emotions, mental health, or disorders, all but alcohol dependence showed significant associa-
use of alcohol or drugs. Among respondents who responded affirmatively, tions with past-year social anxiety disorder.
 H. Wang et al. / Psychiatry Research 220 (2014) 903–908 905

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 2
Sociodemographic correlates of lifetime and past-year social anxiety disorder.

Socio-demographic variable Lifetime social anxiety Past-year social anxiety

disorder OR (95% CI) disorder OR (95% CI)

Age – –
18–25 1.00 1.00
n
26–35 1.41 (1.08–1.96) 1.35 (0.98–1.78)
n
36–45 1.47 (1.15–2.06) 1.40 (1.05–1.86) n
46–55 1.18 (0.88–1.26) 1.09 (0.65–2.25)

Sex – –
Male 1.00 1.00
n n
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) n
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) n 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
n
Grandparents 1.52 (1.22–2.86) 1.48 (1.15–2.31) n
n
Other kinfolks 1.55 (1.35–3.25) 1.35 (1.10–1.68) n

Rank – –
Junior 1.00 1.00
Senior 0.85 (0.75–1.20) 0.73 (0.61–1.06)
n n
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)n 1.30 (1.04–1.85) n
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.
n
po 0.05.

3.3. Relation between social anxiety disorder and health-related In contrast, no significant correlations were found with physical
quality of life health indices.
Table 5 shows the patterns of the use of available resources by
We examined the differences in quality-of-life dimensions military personnel with past-year social anxiety disorder. Subjects
(SF-36 subscales) between the group with social anxiety disorder most frequently reported seeking assistance from psychologists
and the group without social anxiety disorder. Table 4 shows that (20.1%). Psychiatrists' services were the next most commonly used,
the occurrence of social anxiety disorder was associated with poor with 13.5% of individuals with past-year social anxiety disorder
scores on all dimensions of psychological health (po0.01). seeking this type of help. Other types of professional services were
906 H. Wang et al. / Psychiatry Research 220 (2014) 903–908

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) o 0.001 97 (32.1) 13.52 (9.57–19.63) o 0.001
Panic attacks 264 (40.9) 5.17 (4.08–6.58) o 0.001 126 (37.0) 10.26 (7.30–15.87) o 0.001
Panic disorder 62 (10.4) 4.22 (3.32–5.38) o 0.001 48 (14.8) 8.86 (5.07–12.79) o 0.001
GAD 109 (16.1) 7.89 (5.99–10.01) o 0.001 48 (13.8) 17.36 (11.84–25.34) o 0.001
PTSD 100 (15.0) 3.71 (3.01–4.62) o 0.001 57 (15.8) 5.88 (3.87–8.47) o 0.001
Alcohol dependence 61 (9.5) 2.58 (2.27–3.19) o 0.001 23 (6.1) 4.35 (2.13–7.66) o 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 ¼1.00) was respondents without social anxiety
disorder. 95% CI: 95% confidence intervals.

Table 4
Relations between social anxiety disorder and quality-of-life dimensions.

SF-36 subscales SAD(þ ), n ¼355 SAD( ), n¼ 11,172 n ¼11,172 Test of group differences

a
Role-physical χ2 (4, 11,523) ¼33.98
0 141 (39.72%) 3181 (28.47%) po 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%)
a
Role-emotional χ2 (3, 11,524)¼509.73
0 150 (42.25%) 1166 (10.44%) po 0.01
1 75 (21.13%) 983 (8.80%)
2 67 (18.87%) 1326 (11.87%)
3 63 (17.75%) 7697 (68.90%)
a
Social functioning χ2 (3, 11,524)¼211.53
0 100 (28.17%) 1052 (9.42%) po 0.01
1 104 (29.30%) 1854 (16.60%)
2 59 (16.62%) 1967 (17.61%)
3 92 (25.92%) 6299 (56.38%)
b
Mental health 57.88 (22.3) 83.57 (25.5) po 0.01
b
Vitality 47.88 (31.5) 63.26 (39.0) po 0.01
b
General health 68.56 (18.9) 80.30 (34.6) p¼ 0.043
b
Physical functioning 60.66 (32.5) 88.90 (38.9) p¼ 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 5 4. Discussion
Use of resources among military personnel with past-year social anxiety disorder.
The present survey is the first epidemiology study of social
Type of resources % SE
fears and their correlates in the PLA, and it provides significant
Psychiatrist 13.5 1.6
new information about the nature and impact of mental disorders
Psychologist 20.1 2.2 in the active military. Owing to methodological differences, our
Pluralistic counselor 1.2 0.5 findings may not be readily compared with those of Western
General practitioner 0.6 0.2 studies. Nonetheless, our 12-month prevalence estimate (28.7%) of
Telephone helpline 0.8 0.4
social fears is within the range found in Western studies (range:
Internet support group 1.5 0.9
In total 25.4 4.2 24.1–38.6%) (Kessler et al., 1998; Wittchen et al., 1999a, 1999b;
Sareen et al., 2007; Ruscio et al., 2008). The lifetime prevalence
Note: respondents could select more than one resource as having been used in the rate of 6.22%was also similar to a study on Canadian active military
past year; therefore, percentages are not expected to add up to 100.
(Mather et al., 2010), to the European population (Fehm et al.,
Note: the ‘n’ value was not presented due to small sizes, which may compromise
respondent confidentiality.
2005) and to a Japanese clinical population (Takahashi, 1989).
Nevertheless, there are profound differences between Western
and Eastern populations (Stein, 2009).
Overall, 21.2% of officers and soldiers suffered from at least one
used less often. Overall, only 25.4% of those with past-year social social fear. People with social anxiety disorder were characterized
anxiety disorder sought professional service to deal with mental by fear and avoided the scrutiny of others. The concern in such
health problems. The use of other resources, such as internet situations is that the individual will say or do something that will
support groups and telephone help lines, was much less common. result in embarrassment or humiliation. The most frequent social
 H. Wang et al. / Psychiatry Research 220 (2014) 903–908 907

fear was talking to people in authority or a person of a higher status, (8.7%) (Lee et al., 2009) than some Western communities (53.1%)
followed by performing/giving talk in front of an audience, and (Mather et al., 2010), but not all (Sareen et al., 2007). Likewise, the
talking in a meeting or in class. These findings were in agreement present study showed a uniformly low rate (25.4%) of help-
with previous studies (Lee et al., 2009; Mather et al., 2010). seeking, especially professional services. Our study found that
There was an increase in the risk of social anxiety disorder in over 74% of the sample had never sought treatment and that, of
officers, military students, and separated/widowed/divorced people. those, a further 40% cited avoidance factors as being the primary
The gender difference in the prevalence rate of social anxiety reason for this decision. This is consistent with previous studies
disorder was still significant even after adjusting for age and other suggesting that a large proportion of individuals meeting diag-
potential confounding risk factors. Interestingly, this is the first time nostic criteria for an anxiety disorder are unwilling to seek help,
that childhood foster was identified as a risk factor for social anxiety largely due to psychological factors (e.g., their attitudes towards
disorder in the army. A main reason may be that there are more and treatment) (Sareen et al., 2007; Vogel et al., 2007) as opposed to
more “left-behind” children in China. Except for childhood foster, other factors (e.g., accessibility and mental health literacy) (Collins
social anxiety disorder in the PLA was found to share similar risk et al., 2004; Coles and Coleman, 2010). Furthermore, most patients
factors to other studies. In addition, higher education level was in Western populations first seek help from a general practitioner
more related to social anxiety disorder in the army but not in (Sareen et al., 2007; Stein, 2009), while our population first sought
nonmilitary people (Hsu and Alden, 2007; Lee et al., 2009; Osorio help from psychological resources.
et al., 2010). A previous study in Israel, an Eastern country
influenced by Western culture, reported that social anxiety disorder
was associated with the inability to perform command activities, 4.1. Interesting findings in the military related predictors of mental
psychotropic medication, having few friends, and having shy family disorders
members (Iancu et al., 2006).
We observed a strong relationship between the likelihood of The most significant finding of the present study is that child-
meeting criteria for PTSD and social anxiety disorder diagnosis. hood foster was significantly related with social anxiety disorder.
Specifically, many subjects with social anxiety disorder also had We would considerate it as an evidence that the rapid develop-
other psychiatric disorders, which is similar to other studies. For ment of the Chinese society promoted mass migration and the
example, in an examination of over 1000 adult outpatients, the unprecedented tide of rural workers flooding, which led to many
majority of patients with an ongoing principal diagnosis of social children growing up without living with their own parents.
anxiety disorder had an additional Axis I diagnosis (Brown et al.,
2001). Thus, our data concur with prior work, suggesting that only 4.2. Methodological considerations and limitations
a small percentage of adults meet criteria for social anxiety
disorder without the presence of other psychiatric conditions. Some investigators of this study were unfamiliar with the
We observed that panic attacks and depression were the two most established practice. Although diagnoses by clinicians are more
frequent psychiatric conditions associated with social anxiety valid, disarmament and personnel reform resulted in few psychia-
disorder in our subjects. Similar to nonmilitary samples trists working in the military, making it difficult to carry a survey
(Schneier et al., 1992; Magee et al., 1996), social anxiety disorder by psychiatrists in the Chinese army.
was associated with alcohol dependence but not alcohol abuse.
One interpretation is that subjects with social anxiety disorder
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