Gender Difference in Social Anxiety using Social Phobia Inventory - Term Paper Example

Term Paper In the Field of Psychology In Partial Fulfillment of Requirements for The Master of Liberal Arts Degree Harvard Extension School August 6, 2011 Yutong Wu 9 Ellery Street, Unit 25 Cambridge, Massachusetts 02138 (857) 919-7897 ytwu@fas.harvard.edu Tentative Title Exploring gender difference in social anxiety using both Social Phobia Inventory (SPIN) and Trier Social Stress Test (TSST). Social phobia, also known as social anxiety disorder is described in the DSM-IV-TR as a “marked and persistent fear of one or more social and performance situations in which embarrassment may occur” (American Psychiatric Association [DSM-IV-TR], 2000). According to current research anxiety and mood disorders are more common among women. However there is an absence of a significant piece of information to note which is not in the clinical samples among patients with social phobia (DSM-IV-TR, 2000). Based on current few findings the lifetime prevalence of social phobia is higher in women than in men, but males more usually tend to look for treatment (De Menezes, Fontenelle & Versiani, 2008). There is a major lack of data relative to the effect of gender on social anxiety. The aim of this study is to investigate the gender difference in social anxiety using results from both self-report questionnaire and experimental setting. The hope is to bring to light information that can be crucial to use to aid those suffering from social anxiety. This study contains one central question that needs to be addressed: “Is there a gender difference in the experience of social anxiety?” A part of this study also explores whether or not individual experience of social anxiety is fully uncovered by self-report questionnaires. It intends to investigate how male gender roles affect their responses to the questionnaires. It is possible that males tend to underreport their fear and stress than females. This fact alone causes some false information to be conveyed in this area. There is not only an issue with differences in prevalence and clinical samples, the gender experience of social anxiety in men and women also lack discussion. The majority of studies that are completed on social anxiety and social phobia are based on self-report questionnaires. These do not always reveal what the individual with anxiety is actually experiencing, their highs and lows and other crucial information. In considering this topic I suggest that the current findings in gender difference in social anxiety are biased due to gender socialization. The experience of social anxiety provoking situations is the same across genders. Men on an average are equally likely to experience high social anxiety as women. There are a large number of theories and studies done on gender behavioral and psychological differences. For example, the evolutionary neuroandrogenic theory promulgated by Ellis predicts that phobia in general is more common among females than males (Ellis, 2011). Women are more cautious and fearful than males largely due to their diminished pain tolerance (Ellis, 2011). Hence females develop caution and fearfulness, which may interfere with daily lives, resulting in phobia (Ellis, 2011). Gender is embedded so deep inside of us. Most of the time we are blinded by its enormous impact on us and take gender for granted. When we study the gender difference of social anxiety, the investigation itself could be gender biased. Most studies done on the topic are based on self-reports. The process of answering questions can be gendered. Men may underreport their fear and stress due to masculinity. Their background may encourage men to limit their expression about problems such as anxiety thus causing them to feel ashamed about reporting any such information. Society as a whole tends to encourage men to downplay pressing issues. Instead of making assessment of an individual’s anxiety level purely based on self-report measures and questionnaires like most of the studies have been done on social anxiety, I suggest that the use of biological measurements provides more valid insights into the true experience of social anxiety by an individual. In this study, anxiety level of an individual will be investigated by two kinds of assessment, social phobia inventory (SPIN) and Trier Social Stress Test (TSST). SPIN is a self-report assessment containing 17 questions. Results from SPIN in males and females will be compared with cortisol level change measured in TSST. In order to support my hypothesis I am expecting to see a mismatch between the results from SPIN versus TSST in males. Women and men are expected to have equal amount of stress under TSST, but men might report lower stress in SPIN assessment. This occurrence will support my thesis, the questions I set out to answer and the research involved. As in many mental disorders, social phobia has clinical presentation and resulting impairment differing across cultures, age and gender. Many studies have been done on cultural influence and age group differences in social anxiety or social phobia. The gender variance is understudied comparing to the other variables. My study is an attempt to fill this gap. Bringing information to this void will help bridge the gap between the lack of knowledge between gender differences in this field. First of all, it explores gender roles of men and women in terms of social anxiety. In their classic piece of “Doing Gender”, Candace West and Don H. Zimmerman (1987) argued that human beings are engaged in displays that signal others through interaction of who is a man and who is a woman all the time. In other words, gender is omni-relavent. In the context of social anxiety, I propose that in order to display masculinity, men hide their fear and stress during social situations and performances such as public speaking and personal interaction even though the experience is the same as women. Females on the other hand are justified and expected to express their anxious feelings according to femininity. This leads to an under-report by men on their social anxiety. As mentioned earlier most studies done on this topic are community-based studies. The results are based on self-report assessment. Coinciding with their gender, men are expected to underreport their social fear and stress. The second implication of my study is validation of stress level experienced by individuals using biological measurements. Biological responses never lie. Results from cortisol level assessment may be a better indicator of the stress level. If a mismatch is found, future studies should take consideration of changing their method of assessment. Questionnaires could be strongly gender biased when individuals are so involved in their gender roles. Obviously, this would radically alter how research is performed. Moreover, this research is significant in terms of social phobia. There is a growing interest in exploring gender differences concerning impairment associated with high social anxiety. Many argue that there is a need to have normative data according to gender in research studies (Fan, Su, Su, Jin & Cao, 2008). Some also suggest that gender has an effect on clinical features and drug treatment response in social phobia due to the different experience of social anxiety by male and female patients (De Menezes, et al., 2008). A major component of my study is to explore whether or not men and women differ in the experience of their social fears. Results will aim to seek support for whether or not there is a need for different normative data based on different sexes in studies of social phobia concerning a gendered anxiety experience. “Gender” and “sex” are two terms are interchangeably used in literature, which causes confusion in certain contexts. It is important to understand each term independently as they are vastly different. The term “sex” refers to the biological and physiological features that make female and male distinct from one another. Examples are sex hormones or sex genitalia. “Gender” refers to socio-psychological constructed roles, expectations, norms, behaviors and attributes that are defined by society. Gender role is a set of prescriptions and proscriptions for behavior-expectations about what behaviors are appropriate for a person holding a particular position within a particular social context. Gender socialization has been defined by Henslin as "an important part of socialization is the learning of culturally defined gender roles" (1999). It refers to the process of development of behavior and attitudes considered appropriate for a given sex defined by society. Individuals experience social anxiety on a regular basis. The social situations can be public speaking, meeting someone new or having to do with stage performance. Physiological responses such as fast heartbeat or sweating within normal ranges are not diagnosed as social anxiety disorder. DSM-IV-TR states that the essential feature of social phobia is a marked and persistent fear of social or performance situations in which embarrassment may occur (DSM-IV-TR, 2000). Patients that experience all symptoms in criterion A to H on the DSM-IV-TR are diagnosed with social phobia (DSM-IV-TR, 2000). Individuals experiencing social anxiety do not always result in having social phobia. However, patients with social phobia always experience anxiety upon encountering the social or performance situation. Cortisol is a steroid hormone released in response to stress situations. It is used as a biological measure in an experimental setting to assess stress level. As indicated in DSM-IV, social phobia is more common in women than in men based on epidemiological and community-based studies (2000). This is a common feature of most anxiety disorders. However, many studies in the literature suggest the clinical presentation has a larger percentage in male than female. In other words, even though women are more likely to develop social phobia, they are less likely to seek the help they require than males (De Menezes et al., 2008). A few suggestions have been made to account for this phenomenon. De Menezes and colleagues (2008) suggest that there are different degrees of distress and impairment experienced by men and women with the disorder. For example, male patients on an average may encounter more severe symptoms than females. A second potential reason is based on the expectations of western society concerning social performance of individuals according to the gender roles (De Menezes et al., 2008). Men suffering from social phobia would have higher impairment in occupational and social functions than women with social phobia (De Menezes et al., 2008). Social situations and performance may be a bigger part of a man’s life than his female counterparts. Gender socialization plays a big role in how anxious individuals respond to their situations. Whether or not the experience and nature of social anxiety are the same across gender is put into question. Many studies suggest that gender itself is not affecting the outcome of social anxiety. An investigation done on gender effect on clinical features and drug treatment response demonstrated that males and females differed in risk factors of family adversity interactions (DeWit, Chandler-Coutts, Offord, King, McDougall, Specht & Stewart, 2005). The diathesis stress model of anxiety states that a genetic vulnerability only expresses itself to generate an anxiety disorder in the presence of a psychosocial stressor such as family dysfunction (Monroe & Simons, 1991). In this family adversity study DeWit and colleagues (2005) argued that vulnerability of a particular gender only expresses itself in the presence of a risk factor. Absence of a parent or close relatives had a strong association with an elevated risk of developing social phobia in males (DeWit et al., 2005). Females had other unique risk factors including parental conflict and childhood abuse by their fathers (DeWit et al., 2005). According to these results, it is possible to suggest that in the absence of risk factors, the experience of social anxiety could be the same across gender. Another cross-sectional study done on adolescence explored the relevance of gender and age differences in assessment of social fears. Garcia-Lopez and colleagues (2008) aimed to analyze gender difference in the nature of social fears. Results showed that speaking in public was the highest in regards to increasing anxiety in these adolescences (Garcia-Lopez, Ingles & Garcia-Fernandez, 2008). Most importantly even though girls report a higher frequency in social anxiety, boys and girls shared the same social fears (Garcia-Lopez et al., 2008). Girls in this study did show more avoidance behavior than boys (Garcia-Lopez et al., 2008). The authors argued that sex-role socialization process is accounted for this difference. Most studies in the literature list assessment of social anxiety as a limitation. A research study done on social phobia in Swedish adolescents using self-reported scales revealed a significant gender difference (Gren-Landell, Tilfors, Furmark, Bohlin, Andersson & Svedin, 2009). Results are put into question because the assessment is purely based on self-reports of junior high school students. In addition to that, no control was made for socio-demographic factors. As will be mentioned later, socio-demographic and lifestyles play an important role in impairment associated with high social anxiety. A cross-sectional community-based study done in Oslo, Norway examined gender differences in impairment associated with high social anxiety (Dahl & Dahl, 2010). The results did not support any significant sex differences concerning impairment in individuals with high levels of social phobia/anxiety symptoms (SPAS). Significant sex differences of impairment were only found in socio-demographic and lifestyle areas such as lower level of education, non-paired civil status, being non-employed, lowers income, and poorer mental health due to comorbid disorders (Dahl & Dahl, 2010). This study was also purely based on self-report measures. The results might over- or underestimate anxiety levels. Validity of the MINI-SPIN assessment scale is open to consideration. The strength of this study is the large number of individuals that are included in their sample. Hofmann, Asnaani and Hinton (2010) suggested cultural aspects in social anxiety and its disorders. They investigated factors such as individualism/collectivism, perception of social norms, self-construal, gender roles and gender role identification (Hofmann, Asnaani & Hinton, 2010). They concluded that social fears are certainly dependent on cultural aspects (Hofmann et al., 2010). In the section on gender role and gender role identification, Hofmann et al. (2010) stressed on constructs of masculinity and femininity and how they affect social anxiety. Gender role of women is associated with shyness and social subordination and masculinity is associated with dominance and aggression (Hofmann et al., 2010). Gender socialization defines different cultural expectations and norms on the responses to social anxiety by females and males (Hofmann et al., 2010). Biological sex identity might not predict social anxiety experience. It is rather the masculine and feminine gender role orientation generating the perceived difference between males and females. This perceived difference may not reveal the natural experience of anxiety. Research conducted by DeWit et al. (2005) suggests that there is no difference in the experience of social anxiety between men and women in the absence of risk factors. They define risk factors separately for men and women. For women, the risk factors include parental conflict and childhood abuse whereas risk factors for men is basically absence of a close relative. But the presence of these risk factors for either gender is an exceptional case because not all men lose a close relative in their life or are always affected by it. Likewise, only a minute population of women cultivate phobia because pf parental conflict or childhood abuse, if it occurs. Thus, it can be said that DeWit et al. (2005) deny the difference of social anxiety between men and women in general cases. The research conducted by Garcia-Lopez et al. (2008) seconds the findings of DeWit et al (2005) in a slightly different manner. Gracia-Lopez et al. (2008) found that social fears are the same for men and women. The studies conducted by Gren-Landell, Tilfors, Furmark, Bohlin, Andersson & Svedin, (2009) and Dahl and Dahl (2010) found difference in the social anxiety between men and women but both of these studies had collected the data through self-reported questionnaires. Therefore, both validity and reliability of results obtained from these researches is highly questionable. Hence, by reviewing these researches, it can be said that there is a strong body of evidence to suggest similarity of social anxiety in men and women. My study will particularly refute the few studies that challenge this concept. In order to derive the most rational and realistic results, the procedure of conducting the research for measuring social anxiety of men and women should be modified. There has to be stress upon biological results rather than manipulated responses because the biological results are not biased. I intend to follow this trend by following the self-reported questionnaires with the TSST results. The variation in cortisol level will accurately read the social anxiety in both men and women. I will keep the number of male and female respondents same i.e. 35 each, so there is no bias in the process. Methods of assessment in literature focus on semi-structured diagnostic interviews, self-report questionnaires and clinician-administered instruments. One limitation of these instruments is the generalizability of findings from the assessment of patients with diverse backgrounds. Measurement methods are not universal which lead to inconsistency in findings. My assessment method is different from the previous studies in literature. A biological measurement of cortisol will be done on all participants in addition to their self-report questionnaires using SPIN. Cortisol level is expected to change rapidly in human body upon stressful situations. It is measured before and after an experimental procedure that induces stress. Change in cortisol level is used as a measurement of the stress level an individual experiences. The addition to biological measurement to social anxiety assessment helps to advance current methods. Mostly important by comparing results from SPIN to cortisol level change, whether or not there is a gender experience of social anxiety can be studied. Current findings in general demonstrate mixed results. In order to achieve better treatments for patients with social phobia and increase the effectiveness, we have to understand the nature and experience of social anxiety. Current studies in literature lack reliable data due to limitation of assessment methods. My study will advance and extend other research because it seeks support from biological measurement to support claims of social anxiety differences across gender. For the purpose of conducting the research, 70 participants are to be recruited from the study pool at the Psychology Department at Harvard University. I seek a female to male ratio of 1:1 in this study (35 females and 35 males). The reason this is important is because the data must be in equal numbers in order to compare and contrast results. Participants are expected to be in a similar age range within 10 years in difference. Social Phobia Inventory (SPIN) is used to assess anxiety of participants prior to biological measurement. It is a questionnaire containing 17 questions (Connor & Jonathan, 2000). Individuals with extremely high score such that the total assessment score is 41 and above will be excluded from the study. Trier Social Stress Test (TSST) is used to induce stress under laboratory conditions. This allows data collection on biological measurement of stress level. Participants are told that after a rest period, they are to give a speech for five minutes as a job applicant. There is instruction for them to introduce themselves and convince a panel of judge that they are the best candidates for a job opening. Instructors inform the participants that the judges are trained to monitor their nonverbal behavior, and later a voice frequency analysis and an evaluation of their speech performance are to be conducted. Participants follow instructions and are given 10 minutes to prepare their speech during in which time they could create notes using paper and pencil provided. During their speech no aids are allowed. After the speech preparation period, a participant gives his/her speech in front of two judges while being video-and-audio-taped for five minutes. Upon completion of the speech, the judges committee asks the participant to subtract the number 13 from a large prime number as quickly as possible without making any mistakes. If they make a mistake, one of the judges informs by saying “That’s wrong go back to the beginning” and indicates the participant to start the task over. (Firschbaum & Hellhammer, 1993) Salivary cortisol sampling is done as the biological measurement. Samples are to be taken at 2 points, before and after the TSST. Lemon crystals will be used to induce saliva. A cotton ball will be place in their mouths for a minute until saturation. Participants will place it directly into a specimen tube provided. (Bollini & Walker, 2002). A screening process is to be done on all participants prior to the study. Participants with high SPIN scores (41 and above) or fall out of the age range (17-27) will be excluded. Upon qualification to participation, conduction of TSST is done individually on participants. All testing is during the morning hours (9-10:30am) to minimize the effect of individual differences in the diurnal rhythm of cortisol. Thus it is important that all subjects are tested at approximately the same time. Two saliva cortisol samples, before and after the experiment are collected. An informed consent form is given to each participant to sign. Samples are to be sent to physiological laboratory for analysis. Results between males and females from both assessment methods are to be compared. I will use t-test statistics to test for significant difference between males and females. This aids to explore the gender difference in social anxiety. SPIN scores will also be compared to cortisol measurement for each gender. This analysis investigates level of consistency in self-report questionnaire to biological measurement. A t statistics will be used as well to test if there is a significant difference. All research is limited in several ways and this study is no exception. First of all, gender is not the only potential variable associated with social anxiety. Culture, age and socio-economic status have all been suggested to influence impairment associated with high social anxiety. In a community-based study done in Oslo (Dahl & Dahl, 2010), results showed that socio-demographic and lifestyle made significant contributions to social anxiety with 41.6% of the variance. Many other studies also argue that social anxiety peaks in young adulthood in the general population (Giudice, 2011). My study has a focus on gender. Other potential factors may affect the outcome as well. Since an experimental setting is used to induce stress the number of participants in the study is limited. Hence it is difficult to control all confounding variables. Subjects of my study are recruited from psychology undergraduate classes at Harvard University, age and socio-economic status are partially controlled. Nevertheless, social anxiety might be influenced by other variables in addition to gender in this study. Social anxiety is context dependent. Individuals vary in social settings that induce their anxiety. For example, an individual that has high anxiety in public speaking may function perfectly well in personal interaction with other people. Some individuals may avoid eating, drinking or writing in public because of a fear of embarrassment, but they function fine in other social settings. It is very difficult to test all the different situations this could bring about. My study is limited in the social condition that induces stress. TSST is more associated with performance in public. Individuals who are fearful of performing in public may develop anxiety through this experimental procedure. Participants who are socially anxious in other areas may not develop a stress response. SPIN assesses social anxiety of participants in general, which include all social settings. Comparison of results from these two methods may contain inconsistency in addition to the possibility of gender socialization difference. It is difficult to assess social anxiety of an individual in all social setting to obtain biological measurement. Trier Social Stress Test has been used in many previous studies to induce stress and in the literature for some times. The design is by far the best choice to induce social stress. Moreover, cost is a major constraint in this study. Participants are expected to get some credits in their grade, which saves the cost of participant recruitment. However, students in need of grades will come forward to the experiment, others will not. In addition to this, a number of instructors as well as individuals on the judges committee will need to be hired. Experimental setting is a long process. Each participant spends 20 minutes at least in the laboratory. The whole process to induce stressful situation becomes a challenging task in its cost. Saliva cortisol concentration measurement is another major cost in this study. 140 samples will be sent to a physiology laboratory for analysis. The cost for each sample varies, but in general requires a major fund. The number of the participants is limited due to time constraint. In order to avoid individual differences all TSST testing is to be conducted in the morning hours (9-10:30am). This limits the speed of data collection. Due to this time constraint, only 70 participants are to be recruited. This study is primarily directed at determining if there is a difference in the experience of social anxiety according to gender. Preliminary review of literature suggests that there is no difference in the experience of social anxiety between men and women. Although there is a difference between what society expects from the male gender in comparison to the female gender, yet there is no practical difference in the experience of social anxiety. Nevertheless, men tend to hide their social anxiety more than women do because experiencing social anxiety is not consistent with the stereotypical image of their gender. These stereotypical images are a result of the concerted efforts of literature and media that date back to thousands of years since the start of writing. Society believes that men have stronger nerves as compared to women, whereas research has largely shown that difference lies in the degree of expression of anxiety and not in the degree of experiencing the anxiety. Results of the studies concluding that there is disparity in the experience of social anxiety between the male and female gender are based on self-reported questionnaires and are thus doubtful. Results drawn from the analysis of self-reported questionnaires can be challenged because of the tendency of men to hide their fears in order to fit themselves well into the stereotypical image society has constructed for them. On the other hand, women are not as conscious about hiding their anxiety in their response to the self-reported questionnaires because they are supposed to be that way as per society’s expectations. In fact, if they do hide their fears, that would actually make them deviate from what they are supposed to be in the eyes of the society. Therefore, this study will make a rational effort of checking whether or not social anxiety is related to gender by comparing the results obtained from the SPIN self-reported questionnaire to a biological test TSST that will measure their anxiety through change in the hormonal level. Respondents may be able to manipulate their response in the SPIN questionnaire that makes the first part of the experiment, but their biological test would not lie. It is expected that there will be a disparity between the results obtained from the questionnaire and the test for men and this would challenge the results of findings that demonstrate a link between social anxiety and gender. If my hypothesis turns out to be right, this will also mean that there is no need for different normative data for different sexes in the studies of social anxiety. Tentative Schedule Initial submission of proposal April 1, 2012 Proposed return for revision May 15, 2012 Submission of proposal for final revision June 5, 2012 Proposal accepted by research advisor June 15, 2012 Thesis director assigned July 20, 2012 First draft completed November 1, 2012 Thesis director returns corrected first draft December 1, 2012 Revised draft completed January 25, 2013 Thesis director returns revised draft March 1, 2013 Final text submitted to thesis director & research advisor April 25, 2013 Bound copy approved May 10, 2013 Graduation May, 2013 Working Bibliography American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author. Antony, M. M. (1997). Assessment and treatment of social phobia. Canadian Journal of Psychiatry, 42, 826-834. Arrais, K. C., Machado-de-Sousa, J. P., Trzeniak, C., Filho, A. S., Ferrari, M. C. F., Osorio, F. L., Loureiro, S. R., Nardi, A. E., Hetem, L. A. 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