Association of Social Anxiety Disorder and Self-Esteem among Young Adults-A Single Centre Study

Social anxiety disorder is a serious mental health issue in India which often goes undiagnosed and undertreated . In addition, studies have shown social anxiety disorder to have an inverse relation to self-esteem . The aim of the study is to evaluate the association between social anxiety disorder and low self-esteem among young adults. The research is a cross sectional descriptive study among the medical undergraduates. Among the participants suffering from social anxiety disorder many of the individuals had social phobia while a few had traditional social anxiety as well. As a result the prevalence of low self-esteem in the study group has a direct association with social anxiety disorder and shows statistically significant data. Thus, an effective way to deal with this condition would be to spread awareness and establish an active student support system and guidance team on campus.


INTRODUCTION
Social anxiety disorder (SAD) is considered as one of the most common psychiatric disorders ranging from social phobia to traditional social anxiety [1] . One can define social phobia as persistent fear of one or more performance situations in which the person is exposed to unfamiliar people fearing that he or she will act in a way or show anxiety symptoms that will be embarrassing and humiliating [2] . It is a serious mental health problem in India with an incidence of 2.79% and prevalence of 1.47 % [3,4] . The prevalence of social phobia is about 7-13% in Western countries [5] with various studies showing that the males are diagnosed with social phobia more often than the females [6] . The prevalence rate of social phobia is steadily increasing creating a recent interest among psychologists and social scientists [7] . Social phobia increases the risk for developing a major depressive disorder and has a high comorbidity with other mental disorders [8] . Unfortunately, although it is the third most common mental disorder in adults worldwide [1] , SAD is often under diagnosed and undertreated. Twenty-first century is often referred to as the age of anxiety [9] . SAD is increasingly becoming relevant in this present age where students are constantly under immense pressure to perform exceptionally well in studies, extra -curricular activities or even socially. These pressures of life keep increasing as they transit from school to college. While a few handles this with ease, most of the others suffer silently. Social anxiety among college students pointed to various causative factors such as male or female preponderance, social media usage, negative self-image, body consciousness, depression and staying away from family. The Asian cultures emphasizes on interdependence and values in group harmony. Interdependent view of self-definition has been positively correlated with shame or embarrassment and fear of negative evaluations, both of which contribute to Social Anxiety Disorder [10,11] . Social scientists connect self-esteem to a person's general success or competence, particularly in areas of life that are especially meaningful to a given individual. A commonly used definition of self-esteem is an attitude or a sense of worth as a person [12] . People high in self-esteem have positive self-image, build better relationships as they make better impressions on others and show active participation in groups. People low in self-esteem are generally more dependent on others and more susceptible to external cues that carry self-relevant implication. They are also more conservative or cautious in their responses to their social environment [12] . According to the cognitive and emotive models of social anxiety disorder, people with social phobia developing negative outcome about social situations such as fear of negative social performance, negative evaluation by others, and uncontrollable anxiety form the foundation for social anxiety disorder [7] . Studies have shown social phobia in young adults has an inverse relation to self-esteem  [13] . People with low self-esteem display greater sensitivity, show higher levels of depression, hopelessness, and an increased likelihood of suicidal ideation [14] .

AIM OF THE STUDY
To evaluate the association between social anxiety disorder and self-esteem among young adults and to compare the findings with similar such studies.

MATERIAL AND METHODS
The research was a cross sectional descriptive study carried out among the medical undergraduates in the campus of Believers church medical college and hospital.

A. Inclusion criteria
Students from the age group of 18-25 years who were willing to take part in this study.

B. Exclusion criteria
Those who did not wish to participate in the study were excluded.

C. Data collection
Participants were asked to fill out 2 questionnaires i.e., Social Interaction Anxiety Scale (SIAS) [15] for social phobia and Rosenberg self-esteem questionnaire [16] for self-esteem. Social interaction anxiety scale (SIAS) is a 20-item scale designed to assess Social Anxiety among undergraduate students. The 20 items of the scale have a Likert type five-point rating based on a response scale of "not at all characteristic or untrue of me", to "extremely characteristic or true of me". For items 5, 9 and 11, reverse scoring was done. Rosenberg self-esteem scale is a widely used self-report instrument for evaluating individual self-esteem. It is a ten item Likert scale with items answered on a four-point scale -from strongly agree to strongly disagree. Complete confidentiality of the participants and their data was maintained throughout the study. Points were given to each degree and scoring was done. The collected data was analyzed using SPSS program and Chi-square test was used for data analysis. It was approved by the institutional ethics committee.

RESULTS
The research group comprised of 195 participants of which 138 were females and 57 were males. Among the 195 participants 28 individuals suffered from social phobia and 24 individuals displayed traditional social anxiety with no gender difference. The prevalence of social phobia was 9.7% among females(n=19) and 4.6% among males(n=9) whereas the prevalence of traditional social anxiety was 7.2% in females (n=14) and 5.2% in males (n=10), the difference being statistically insignificant. The prevalence of low self-esteem was found to be 17.9% (n=35) in the participant group of which 12.8% were females (n=25) and 5.1% were males(n=10)

Self Esteem
The prevelance of high self-esteem was found to be 8.2% (n=16) in the participant group whereas with normal self esteem was found to be 73.8% (n=144). The highest prevalence (n=20) of social anxiety disorder was found in the group with low self-esteem which was found to be statistically significant (p<0.001). Social anxiety disorder was lowest (n=32) among those with normal or high self-esteem. It shows that low self-esteem is a risk factor for social anxiety disorder.

DISCUSSION
In this descriptive cross-sectional study of 195 participants (138 females and 57 males) our aim was to investigate the association between social anxiety disorder and self-esteem while also reflecting on its prevalence among young adults. In our study the prevalence of social anxiety disorder was found to be 26.6%. Among this group 14.3 % of individuals had social phobia and 12.3% had traditional social anxiety. In the study done by Shah and Kataria [17] among Indian university students the prevalence of social phobia was found to be 19.5%. Singh et al reported the prevalence of social anxiety and social phobia among postgraduate students using the SIAS tool as 21% and 22% respectively [18] . A range of prevalence rates were seen in different studies such as Ratnani et al (11.37%) [19] , Baptista et al (11.6%) [20] , and Ganapathi et al (12.9%) [21] . Females experienced higher social anxiety disorder which was reflected in our results as the prevalence of social phobia and traditional social anxiety was much greater in females (9.7% and 7.2%) than in males (4.6% and 5.2%) however this difference was insignificant. Mascarenhas et al found SAD to be more common among females (24%) among the paramedical students and more prevalent in males among the medical students (20%) [22] . The prevalence of low self-esteem in our study was 17.9 % which was similar to that by Bidyadhar SA et al at 21% [23] . Various studies have consistently shown that self-esteem, self-criticism, dependency, and self-efficacy are related to SAD [13,24] . A study by Rosenberg in 1965 also revealed that self-esteem is associated with anxiety disorders, and low self-esteem had an important role in adolescents suffering from social phobia [16] . We also noted that among the individuals having low self-esteem, 57.14% individuals had social anxiety disorder. The highest prevalence of social anxiety disorder was found in the group with low self-esteem which was statistically significant (p<0.001). Social anxiety disorder was lowest, 20% among those with normal to high self-esteem. It shows that low self-esteem is a risk factor for social anxiety disorder. Those who had low self-esteem were 5.33 times more prone to develop social anxiety than those with normal or high self-esteem. (odds ratio= 5.33). Various studies done by authors such as Iancu I et al [24] , Izgic et al [7] found that self-esteem was significantly lower among those with social phobia than among those without social phobia which was consistent with our findings. Peter de Jong found that socially anxious women displayed relatively lower levels of self-esteem [25] with a strong association between symptoms of depression and social anxiety that could be largely explained within the study participants with explicit self-esteem. Individuals with low self-esteem carry a negative self-image and constantly battle the fear of being rejected in society. Thus, these set of people try to avoid situations which make them extremely nervous when interacting with strangers, speaking in front of a crowd, or giving a critical opinion which are a few of the symptoms of social anxiety disorder. In contrast individuals with high self-esteem are confident and comfortable with their self-image and form social relationships more easily.

CONCLUSION
The highest prevalence of social anxiety disorder was found in the group with low self-esteem that was statistically significant meaning that students with low self-esteem have more chance of having social anxiety disorder compared to those students who have higher self-esteem. Though females outnumber the males in increased prevalence rates of social anxiety disorder, the difference was insignificant. An effective way to deal with this issue would be to spread awareness among the teaching staff and students and make provisions for an active student support and guidance team, both online and on campus, that offers a confidential and nonjudgmental space in which students feel safe to convey their problems. Students should be encouraged to avail the services of the support team and should be provided with guidance and counselling as required.

LIMITATIONS
This study was done among a small population of medical students and thus does not represent the general population. It is necessary to study a representative sample from the entire population to achieve more sound results. Many students were not willing to participate in the study due to various reasons, so the accuracy of the sample size is not obtained. A prospective longitudinal study would be required to assess social anxiety disorders among young adults.