Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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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 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 b
art ic l e i nf o
a b s t r a c t
Article history: Received 17 June 2013 Received in revised form 25 February 2014 Accepted 27 July 2014
The objective of this work is To investigate the prevalence, comorbidities, impairment, and treatmentseeking of social anxiety disorder in the Chinese military personnel. Military personnel (n¼ 11,527) were surveyed from May to August 2007 using a multistage whole cohort probability sampling method. A Chinese version of the World Health Organization Composite International Diagnostic Interview (CIDI) was used for 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 health survey was used to assess role impairment. The 12-month and lifetime prevalence rates of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. Social anxiety disorder was associated with increased odds of depression, substance abuse, panic attacks/disorder, and generalized anxiety disorder. Childhood foster, female, stressful life events, younger age, and being divorced/ 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.
Keywords: Social anxiety disorders Chinese military personnel Epidemiology Comorbidity
1. Introduction Social anxiety is pervasive, with a majority of people expressing discomfort in at least one type of social situation (Stein et al., 1994). Investigation of social anxiety disorder in representative civilian showed that social anxiety disorder has a high lifetime prevalence of approximately 5–12% (Kessler and Ustun, 2004; Shields, 2004; Grant et al., 2005; Stein, 2006; Hsu and Alden, 2007). Social anxiety disorder is associated with increased disability, decreased quality of life, poor role functioning, and suicidal behavior (Stein and Kean, 2000; Wittchen et al., 2000; Wittchen and Fehm, 2001; Simon et al., 2002; Shields, 2004; Ruscio et al., 2008; Mather et al., 2010). In addition, social anxiety disorder has been shown to be a risk factor for the development of major depression (Stein et al., 2001; Beesdo et al., 2007;Mather et al., 2010). Recently, a comprehensive examination of the epidemiology and characteristics of social anxiety disorder in a representative sample of active military
n
Corresponding author. Tel.: þ 86 13609161341; fax: þ 86 29 83293951. E-mail address: [email protected] (Q. Tan). 1 Co-first authors.
personnel showed that the military population had characteristics that were similar to the general population (Mather et al., 2010). In the Israeli military, the rate of social phobia was 4.5% (Iancu et al., 2006). Therefore, social anxiety disorder is an extremely important disorder in both general and military populations. Furthermore, the impacts of social anxiety disorders could be exacerbated in military personnel, since they are exposed to situations like adaptation to new places, exposure, discipline, stress associated with ranks and combat situations (Sareen et al., 2007). In China, military service is not compulsory, but the discipline is very strict. Furthermore, the age at enlistment is relatively young, and a large proportion of recruits are from rural areas (Wang et al., 1996). There are few recent reports on the mental health of Chinese military personnel since a mental disorder survey carried in 1994 (Wang et al., 1996). In addition, most studies on the mental health in the military tend to focus on post-traumatic stress disorder (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 of social anxiety disorder and social fears in the military, and determined the sociodemographic correlates and role impairment 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.
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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anxiety disorder is related to other mental disorders among military personnel, and examined whether social anxiety disorder interacts with the incidence of other mental disorders. Finally, we determined the frequency of treatment-seeking in military personnel who meet criteria for a diagnosis of social anxiety disorder.
information was collected regarding the types of services used. This information was used to characterize whether military personnel with social anxiety disorder seek help for their social fears and, if so, what types of help are sought.
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 treatment-seeking. Standard errors were estimated using the Taylor series linearization method (Wolter, 1985) implemented in the SAS8.2 software (SAS Institute, Cary, NY, USA) to adjust for the clustering and weighting of data. The stepwise logistic regression model method was used to examine the odds of meeting criteria for social anxiety disorder among the various social fear categories, the relationship between number of social fears and likelihood of mental disorder comorbidities, and the sociodemographic correlates of social anxiety disorder. Statistical significance was based on two-sided tests evaluated at a 0.05 level of significance.
2.1. Subjects Surveyed subjects included active soldiers in service, officers ranked below lieutenant, and students in military universities, all among the Land Forces, Navy, Air Forces and Missilery Forces of the People Liberation Army (PLA) in China. 2.2. Sampling 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 (82.33%). Additional factors were used to adjust for differential probabilities to match the samples to military region and Army Services distributions. 2.3. Measures 2.3.1. Psychiatric diagnoses The WHO Composite International Diagnostic Interview (CIDI 3.0), a fully structured diagnostic interview, was used for psychiatric diagnosis (Kessler and Ustun, 2004; Kessler et al., 2005). Both the International Classification of Diseases (ICD-10) (Demyttenaere et al., 2004) and Diagnostic and Statistical Manual (DSM-IV) (1994) diagnoses were examined; DSM-IV diagnoses were used in the present study. A military-related sociodemographic questionnaire was used to 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 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 Medical University (Xi'an, China). 2.3.2. Social fears Eleven different social situations were investigated using a previously described method (Lee et al., 2009; Mather et al., 2010). Briefly, a unified survey was performed to investigate whether the respondents had ever felt shy, uncomfortable, or afraid in any of 11 different social situations (such as meeting new people, working while someone was watching, using public washrooms, etc.). Two qualitative and quantitative variables were created to analyze the associations between the number of social fears and a variety of outcomes, such as mental disorder comorbidities. 2.3.3. Role impairment 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 fear were asked to which extent their health domains (physical functioning; social functioning; daily role limitations) were impaired in the past year by their fear or avoidance. For all subscales, higher scores reflected better mental health. The SF-36 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 Health Survey Manual) (Ware, 1997). Due to non-normal distributions, 3 subscales were transformed into categorical variables based on response distributions (i.e., role-physical on a 0–4 scale; social functioning and role-emotional on a 0–3 scale). 2.3.4. Sociodemographic variables A number of sociodemographic variables were examined to determine their association with social anxiety disorder and particular social fears. Specifically, age, gender, childhood foster (real parents vs. foster parents), trauma history during duty (negative vs. positive), rank (soldier, petty officer and officer), education, military rank, and arm of the service were included. 2.3.5. Treatment-seeking 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 whether they had sought help for problems with their emotions, mental health, or use of alcohol or drugs. Among respondents who responded affirmatively,
2.4. Analysis methods
3. Results 3.1. Demographic distribution The mean age of the subjects was 22.0 73.79 years, without significant differences among the different military regions. Most subjects (98.0%) were male. The arm distribution of the final sample was: Land Forces 59.74%, Navy 13.26%, Air Forces 9.06%, Missilery Forces 8.31%, Military Students 4.07%, and Other Forces 5.55%, which was consistent with the general population of the PLA. The final sample properly covered all military regions in China.
3.2. Prevalence For the entire sample, 3.08% of subjects (n ¼355) met criteria for SAD diagnosis. The twelve-month and lifetime prevalence rates of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. The prevalence of social fears is presented in Table 1. The 12-month prevalence for at least one social fear was 21.2%. The most and least common social fears were “talking to people in authority or a person of a higher status” (18.9%) and “using public washrooms” (7.4%), respectively. As demonstrated in Table 2, social anxiety disorder was associated with a number of sociodemographic variables. The low and intermediate social fear groups were significantly younger and more educated than respondents without any social fear. Childhood foster was significantly related to social anxiety disorder among military personnel. Female was more likely to suffer from social anxiety disorder. Individuals who were separated, widowed, or divorced had a higher likelihood of past-year social anxiety disorder (OR ¼2.21, 95% CI 1.38–3.31). Officers were less likely than those of junior rank to have either past-year (OR ¼0.49, 95% CI 0.12–0.85) or lifetime (OR ¼0.56, 95% CI 0.31–0.89) social anxiety disorder. After adjusting for demographic characteristics and multiple comparisons, we examined the risk of psychiatric disorders associated with the occurrence of social anxiety disorder. As shown in Table 3, military personnel diagnosed with social anxiety disorder were significantly more likely than those without social anxiety disorder to have any lifetime or past-year mental disorder. In respect of lifetime prevalence, the analytic mental disorders (depression, panic attacks, panic disorder, generalized anxiety disorder, and post-traumatic stress disorder) were significantly associated with social anxiety disorder. Similarly, of the past-year disorders, all but alcohol dependence showed significant associations with past-year social anxiety disorder.
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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Table 1 Prevalence of individual social fears among military personnel. Social fear
n (%)
Talking to people in authority or a person of a higher status Performing/giving talk in front of audience Talking in a meeting or in class Other social/performance situation Meeting strangers Public performance Working, writing, eating, or drinking under others' attention Entering a room when others are already present Talking to unfamiliar others Joining gatherings Using public washrooms At least one social fear
2130 1928 1727 1687 1532 1517 1455 1229 1200 1097 853 2299
SE (18.9) (17.3) (15.4) (15.2) (13.6) (13.5) (12.8) (11.0) (10.7) (9.8) (7.4) (21.2)
0.41 0.40 0.39 0.38 0.37 0.37 0.36 0.34 0.34 0.33 0.29 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 disorder OR (95% CI)
Past-year social anxiety disorder OR (95% CI)
Age 18–25 26–35 36–45 46–55
– 1.00 1.41 (1.08–1.96) 1.47 (1.15–2.06) 1.18 (0.88–1.26)
– 1.00 1.35 (0.98–1.78) 1.40 (1.05–1.86) n 1.09 (0.65–2.25)
Sex Male Female
– 1.00 1.35 (1.18–1.86)
Marital status Married/common law Separated/widowed/divorced Single
– 1.00 1.32 (0.96–1.89) 0.96 (0.58–1.96)
– 1.00 2.21 (1.38–3.31) n 0.94 (0.68–1.53)
Education Less than high school High school graduate Other post-secondary Post-secondary graduate
– 1.00 1.42 (1.11–2.23) n 1.25 (0.74–1.80) 1.05 (0.88–1.33)
– 1.00 1.35 (0.87–1.69) 1.13 (0.56–2.00) 0.95 (0.68–1.46)
Childhood foster Own parents Grandparents Other kinfolks
– 1.00 1.52 (1.22–2.86) 1.55 (1.35–3.25)
– 1.00 1.48 (1.15–2.31) n 1.35 (1.10–1.68) n
Rank Junior Senior Officer
– 1.00 0.85 (0.75–1.20) 0.56 (0.31–0.89)
Arm of the service Land Forces Navy Air Forces Missilery Forces Military Student Other Forces
– 1.00 0.98 (0.88–1.45) 1.15 (0.74–2.32) 1.29 (0.96–1.35) 1.32 (1.09–1.66)n 1.24 (0.65–2.95)
n n
n
n n
n
– 1.00 1.68 (1.31–2.27)
– 1.00 0.73 (0.61–1.06) 0.49 (0.12–0.85)
n
n
– 1.00 0.96 (0.76–1.53) 1.11 (0.86–1.46) 1.21 (0.67–2.01) 1.30 (1.04–1.85) n 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 quality of life We examined the differences in quality-of-life dimensions (SF-36 subscales) between the group with social anxiety disorder and the group without social anxiety disorder. Table 4 shows that the occurrence of social anxiety disorder was associated with poor scores on all dimensions of psychological health (po0.01).
In contrast, no significant correlations were found with physical health indices. Table 5 shows the patterns of the use of available resources by military personnel with past-year social anxiety disorder. Subjects most frequently reported seeking assistance from psychologists (20.1%). Psychiatrists' services were the next most commonly used, with 13.5% of individuals with past-year social anxiety disorder seeking this type of help. Other types of professional services were
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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Table 3 Morbidity of lifetime and past-year social anxiety disorder and other common psychiatric disorders. Diagnosis from CIDI
Lifetime social anxiety disorder
Psychiatric condition
n (%)
AOR (95% CI)
p
n (%)
AOR (95% CI)
p
Depression Panic attacks Panic disorder GAD PTSD Alcohol dependence
201 264 62 109 100 61
6.32 5.17 4.22 7.89 3.71 2.58
o 0.001 o 0.001 o 0.001 o 0.001 o 0.001 o 0.001
97 126 48 48 57 23
13.52 10.26 8.86 17.36 5.88 4.35
o 0.001 o 0.001 o 0.001 o 0.001 o 0.001 o 0.001
(31.0) (40.9) (10.4) (16.1) (15.0) (9.5)
Past-year social anxiety disorder
(4.87–7.11) (4.08–6.58) (3.32–5.38) (5.99–10.01) (3.01–4.62) (2.27–3.19)
(32.1) (37.0) (14.8) (13.8) (15.8) (6.1)
(9.57–19.63) (7.30–15.87) (5.07–12.79) (11.84–25.34) (3.87–8.47) (2.13–7.66)
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. SAD(þ ), n ¼355
SF-36 subscales Role-physical 0 1 2 3 4
Social functioning 0 1 2 3 Mental health
(39.72%) (12.39%) (12.68%) (22.25%) (12.96%)
3181 1732 1977 2039 2243
(28.47%) (15.50%) (17.70%) (18.25%) (20.08%)
150 75 67 63
(42.25%) (21.13%) (18.87%) (17.75%)
1166 983 1326 7697
(10.44%) (8.80%) (11.87%) (68.90%)
100 104 59 92
(28.17%) (29.30%) (16.62%) (25.92%)
1052 1854 1967 6299
(9.42%) (16.60%) (17.61%) (56.38%)
a
b
b
General health
141 44 45 79 46 a
Role-emotional 0 1 2 3
Vitality
SAD( ), n¼ 11,172 n ¼11,172
a
b
Physical functioning
b
Test of group differences χ2 (4, 11,523) ¼33.98 po 0.01
χ2 (3, 11,524)¼509.73 po 0.01
χ2 (3, 11,524)¼211.53 po 0.01
57.88 (22.3)
83.57 (25.5)
47.88 (31.5)
63.26 (39.0)
po 0.01 po 0.01
68.56 (18.9)
80.30 (34.6)
p¼ 0.043
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 Use of resources among military personnel with past-year social anxiety disorder. Type of resources
%
SE
Psychiatrist Psychologist Pluralistic counselor General practitioner Telephone helpline Internet support group In total
13.5 20.1 1.2 0.6 0.8 1.5 25.4
1.6 2.2 0.5 0.2 0.4 0.9 4.2
Note: respondents could select more than one resource as having been used in the past year; therefore, percentages are not expected to add up to 100. Note: the ‘n’ value was not presented due to small sizes, which may compromise respondent confidentiality.
used less often. Overall, only 25.4% of those with past-year social anxiety disorder sought professional service to deal with mental health problems. The use of other resources, such as internet support groups and telephone help lines, was much less common.
4. Discussion The present survey is the first epidemiology study of social fears and their correlates in the PLA, and it provides significant new information about the nature and impact of mental disorders in the active military. Owing to methodological differences, our findings may not be readily compared with those of Western studies. Nonetheless, our 12-month prevalence estimate (28.7%) of social fears is within the range found in Western studies (range: 24.1–38.6%) (Kessler et al., 1998; Wittchen et al., 1999a, 1999b; Sareen et al., 2007; Ruscio et al., 2008). The lifetime prevalence rate of 6.22%was also similar to a study on Canadian active military (Mather et al., 2010), to the European population (Fehm et al., 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 social fear. People with social anxiety disorder were characterized by fear and avoided the scrutiny of others. The concern in such situations is that the individual will say or do something that will result in embarrassment or humiliation. The most frequent social
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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fear was talking to people in authority or a person of a higher status, followed by performing/giving talk in front of an audience, and talking in a meeting or in class. These findings were in agreement with previous studies (Lee et al., 2009; Mather et al., 2010). There was an increase in the risk of social anxiety disorder in officers, military students, and separated/widowed/divorced people. The gender difference in the prevalence rate of social anxiety disorder was still significant even after adjusting for age and other potential confounding risk factors. Interestingly, this is the first time that childhood foster was identified as a risk factor for social anxiety disorder in the army. A main reason may be that there are more and more “left-behind” children in China. Except for childhood foster, social anxiety disorder in the PLA was found to share similar risk factors to other studies. In addition, higher education level was more related to social anxiety disorder in the army but not in nonmilitary people (Hsu and Alden, 2007; Lee et al., 2009; Osorio 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, psychotropic medication, having few friends, and having shy family members (Iancu et al., 2006). We observed a strong relationship between the likelihood of meeting criteria for PTSD and social anxiety disorder diagnosis. Specifically, many subjects with social anxiety disorder also had other psychiatric disorders, which is similar to other studies. For example, in an examination of over 1000 adult outpatients, the majority of patients with an ongoing principal diagnosis of social anxiety disorder had an additional Axis I diagnosis (Brown et al., 2001). Thus, our data concur with prior work, suggesting that only a small percentage of adults meet criteria for social anxiety disorder without the presence of other psychiatric conditions. We observed that panic attacks and depression were the two most frequent psychiatric conditions associated with social anxiety disorder in our subjects. Similar to nonmilitary samples (Schneier et al., 1992; Magee et al., 1996), social anxiety disorder was associated with alcohol dependence but not alcohol abuse. One interpretation is that subjects with social anxiety disorder frequently consume large quantities of alcohol that inevitably leads to dependence, but the discipline avoids excessive alcohol use. The finding that social anxiety disorder increased the odds of developing PTSD is of particular interest. This suggests that social anxiety disorder may be a risk factor for PTSD, but further investigation is needed. These findings further suggest that preventive measures could be taken among those with social anxiety disorder to reduce the chances that they develop PTSD or other mental disorders. There is an intimate relationship between social anxiety disorder and quality-of-life. As expected, respondents in the intermediate and high social fear groups reported significantly more physical symptoms than those in the low social fear group (Wittchen et al., 1999a, 1999b). Moreover, palpitations, blushing, voice shaking, and stammering significantly differentiated the intermediate and high social fear groups from the low social fear group. Being more socially noticeable, these physical symptoms may arouse more embarrassment that in turn exacerbates social anxiety. However, in this study, we only observed that social anxiety disorder was associated with poor scores on all dimensions of psychological health, and that no significant relations were found with physical health scores. One interpretation is that all subjects in this study had military training, and that their physical adaptive capability was better than nonmilitary people. Another possibility is that there is little personal or social value in light physical symptoms in cultural contexts with low levels of prevention focus. A previous study reported that Chinese individuals with social anxiety disorder exhibited a much lower treatment-seeking rate
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(8.7%) (Lee et al., 2009) than some Western communities (53.1%) (Mather et al., 2010), but not all (Sareen et al., 2007). Likewise, the present study showed a uniformly low rate (25.4%) of helpseeking, especially professional services. Our study found that over 74% of the sample had never sought treatment and that, of those, a further 40% cited avoidance factors as being the primary reason for this decision. This is consistent with previous studies suggesting that a large proportion of individuals meeting diagnostic criteria for an anxiety disorder are unwilling to seek help, largely due to psychological factors (e.g., their attitudes towards treatment) (Sareen et al., 2007; Vogel et al., 2007) as opposed to other factors (e.g., accessibility and mental health literacy) (Collins et al., 2004; Coles and Coleman, 2010). Furthermore, most patients in Western populations first seek help from a general practitioner (Sareen et al., 2007; Stein, 2009), while our population first sought help from psychological resources. 4.1. Interesting findings in the military related predictors of mental disorders The most significant finding of the present study is that childhood foster was significantly related with social anxiety disorder. We would considerate it as an evidence that the rapid development of the Chinese society promoted mass migration and the unprecedented tide of rural workers flooding, which led to many children growing up without living with their own parents. 4.2. Methodological considerations and limitations Some investigators of this study were unfamiliar with the established practice. Although diagnoses by clinicians are more valid, disarmament and personnel reform resulted in few psychiatrists working in the military, making it difficult to carry a survey by psychiatrists in the Chinese army.
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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 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 b
art ic l e i nf o
a b s t r a c t
Article history: Received 17 June 2013 Received in revised form 25 February 2014 Accepted 27 July 2014
The objective of this work is To investigate the prevalence, comorbidities, impairment, and treatmentseeking of social anxiety disorder in the Chinese military personnel. Military personnel (n¼ 11,527) were surveyed from May to August 2007 using a multistage whole cohort probability sampling method. A Chinese version of the World Health Organization Composite International Diagnostic Interview (CIDI) was used for 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 health survey was used to assess role impairment. The 12-month and lifetime prevalence rates of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. Social anxiety disorder was associated with increased odds of depression, substance abuse, panic attacks/disorder, and generalized anxiety disorder. Childhood foster, female, stressful life events, younger age, and being divorced/ 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.
Keywords: Social anxiety disorders Chinese military personnel Epidemiology Comorbidity
1. Introduction Social anxiety is pervasive, with a majority of people expressing discomfort in at least one type of social situation (Stein et al., 1994). Investigation of social anxiety disorder in representative civilian showed that social anxiety disorder has a high lifetime prevalence of approximately 5–12% (Kessler and Ustun, 2004; Shields, 2004; Grant et al., 2005; Stein, 2006; Hsu and Alden, 2007). Social anxiety disorder is associated with increased disability, decreased quality of life, poor role functioning, and suicidal behavior (Stein and Kean, 2000; Wittchen et al., 2000; Wittchen and Fehm, 2001; Simon et al., 2002; Shields, 2004; Ruscio et al., 2008; Mather et al., 2010). In addition, social anxiety disorder has been shown to be a risk factor for the development of major depression (Stein et al., 2001; Beesdo et al., 2007;Mather et al., 2010). Recently, a comprehensive examination of the epidemiology and characteristics of social anxiety disorder in a representative sample of active military
n
Corresponding author. Tel.: þ 86 13609161341; fax: þ 86 29 83293951. E-mail address: [email protected] (Q. Tan). 1 Co-first authors.
personnel showed that the military population had characteristics that were similar to the general population (Mather et al., 2010). In the Israeli military, the rate of social phobia was 4.5% (Iancu et al., 2006). Therefore, social anxiety disorder is an extremely important disorder in both general and military populations. Furthermore, the impacts of social anxiety disorders could be exacerbated in military personnel, since they are exposed to situations like adaptation to new places, exposure, discipline, stress associated with ranks and combat situations (Sareen et al., 2007). In China, military service is not compulsory, but the discipline is very strict. Furthermore, the age at enlistment is relatively young, and a large proportion of recruits are from rural areas (Wang et al., 1996). There are few recent reports on the mental health of Chinese military personnel since a mental disorder survey carried in 1994 (Wang et al., 1996). In addition, most studies on the mental health in the military tend to focus on post-traumatic stress disorder (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 of social anxiety disorder and social fears in the military, and determined the sociodemographic correlates and role impairment 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.
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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anxiety disorder is related to other mental disorders among military personnel, and examined whether social anxiety disorder interacts with the incidence of other mental disorders. Finally, we determined the frequency of treatment-seeking in military personnel who meet criteria for a diagnosis of social anxiety disorder.
information was collected regarding the types of services used. This information was used to characterize whether military personnel with social anxiety disorder seek help for their social fears and, if so, what types of help are sought.
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 treatment-seeking. Standard errors were estimated using the Taylor series linearization method (Wolter, 1985) implemented in the SAS8.2 software (SAS Institute, Cary, NY, USA) to adjust for the clustering and weighting of data. The stepwise logistic regression model method was used to examine the odds of meeting criteria for social anxiety disorder among the various social fear categories, the relationship between number of social fears and likelihood of mental disorder comorbidities, and the sociodemographic correlates of social anxiety disorder. Statistical significance was based on two-sided tests evaluated at a 0.05 level of significance.
2.1. Subjects Surveyed subjects included active soldiers in service, officers ranked below lieutenant, and students in military universities, all among the Land Forces, Navy, Air Forces and Missilery Forces of the People Liberation Army (PLA) in China. 2.2. Sampling 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 (82.33%). Additional factors were used to adjust for differential probabilities to match the samples to military region and Army Services distributions. 2.3. Measures 2.3.1. Psychiatric diagnoses The WHO Composite International Diagnostic Interview (CIDI 3.0), a fully structured diagnostic interview, was used for psychiatric diagnosis (Kessler and Ustun, 2004; Kessler et al., 2005). Both the International Classification of Diseases (ICD-10) (Demyttenaere et al., 2004) and Diagnostic and Statistical Manual (DSM-IV) (1994) diagnoses were examined; DSM-IV diagnoses were used in the present study. A military-related sociodemographic questionnaire was used to 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 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 Medical University (Xi'an, China). 2.3.2. Social fears Eleven different social situations were investigated using a previously described method (Lee et al., 2009; Mather et al., 2010). Briefly, a unified survey was performed to investigate whether the respondents had ever felt shy, uncomfortable, or afraid in any of 11 different social situations (such as meeting new people, working while someone was watching, using public washrooms, etc.). Two qualitative and quantitative variables were created to analyze the associations between the number of social fears and a variety of outcomes, such as mental disorder comorbidities. 2.3.3. Role impairment 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 fear were asked to which extent their health domains (physical functioning; social functioning; daily role limitations) were impaired in the past year by their fear or avoidance. For all subscales, higher scores reflected better mental health. The SF-36 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 Health Survey Manual) (Ware, 1997). Due to non-normal distributions, 3 subscales were transformed into categorical variables based on response distributions (i.e., role-physical on a 0–4 scale; social functioning and role-emotional on a 0–3 scale). 2.3.4. Sociodemographic variables A number of sociodemographic variables were examined to determine their association with social anxiety disorder and particular social fears. Specifically, age, gender, childhood foster (real parents vs. foster parents), trauma history during duty (negative vs. positive), rank (soldier, petty officer and officer), education, military rank, and arm of the service were included. 2.3.5. Treatment-seeking 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 whether they had sought help for problems with their emotions, mental health, or use of alcohol or drugs. Among respondents who responded affirmatively,
2.4. Analysis methods
3. Results 3.1. Demographic distribution The mean age of the subjects was 22.0 73.79 years, without significant differences among the different military regions. Most subjects (98.0%) were male. The arm distribution of the final sample was: Land Forces 59.74%, Navy 13.26%, Air Forces 9.06%, Missilery Forces 8.31%, Military Students 4.07%, and Other Forces 5.55%, which was consistent with the general population of the PLA. The final sample properly covered all military regions in China.
3.2. Prevalence For the entire sample, 3.08% of subjects (n ¼355) met criteria for SAD diagnosis. The twelve-month and lifetime prevalence rates of social anxiety disorder were 3.34% (95% CI: 3.25–3.42%) and 6.22% (95% CI: 6.11–6.32%), respectively. The prevalence of social fears is presented in Table 1. The 12-month prevalence for at least one social fear was 21.2%. The most and least common social fears were “talking to people in authority or a person of a higher status” (18.9%) and “using public washrooms” (7.4%), respectively. As demonstrated in Table 2, social anxiety disorder was associated with a number of sociodemographic variables. The low and intermediate social fear groups were significantly younger and more educated than respondents without any social fear. Childhood foster was significantly related to social anxiety disorder among military personnel. Female was more likely to suffer from social anxiety disorder. Individuals who were separated, widowed, or divorced had a higher likelihood of past-year social anxiety disorder (OR ¼2.21, 95% CI 1.38–3.31). Officers were less likely than those of junior rank to have either past-year (OR ¼0.49, 95% CI 0.12–0.85) or lifetime (OR ¼0.56, 95% CI 0.31–0.89) social anxiety disorder. After adjusting for demographic characteristics and multiple comparisons, we examined the risk of psychiatric disorders associated with the occurrence of social anxiety disorder. As shown in Table 3, military personnel diagnosed with social anxiety disorder were significantly more likely than those without social anxiety disorder to have any lifetime or past-year mental disorder. In respect of lifetime prevalence, the analytic mental disorders (depression, panic attacks, panic disorder, generalized anxiety disorder, and post-traumatic stress disorder) were significantly associated with social anxiety disorder. Similarly, of the past-year disorders, all but alcohol dependence showed significant associations with past-year social anxiety disorder.
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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Table 1 Prevalence of individual social fears among military personnel. Social fear
n (%)
Talking to people in authority or a person of a higher status Performing/giving talk in front of audience Talking in a meeting or in class Other social/performance situation Meeting strangers Public performance Working, writing, eating, or drinking under others' attention Entering a room when others are already present Talking to unfamiliar others Joining gatherings Using public washrooms At least one social fear
2130 1928 1727 1687 1532 1517 1455 1229 1200 1097 853 2299
SE (18.9) (17.3) (15.4) (15.2) (13.6) (13.5) (12.8) (11.0) (10.7) (9.8) (7.4) (21.2)
0.41 0.40 0.39 0.38 0.37 0.37 0.36 0.34 0.34 0.33 0.29 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 disorder OR (95% CI)
Past-year social anxiety disorder OR (95% CI)
Age 18–25 26–35 36–45 46–55
– 1.00 1.41 (1.08–1.96) 1.47 (1.15–2.06) 1.18 (0.88–1.26)
– 1.00 1.35 (0.98–1.78) 1.40 (1.05–1.86) n 1.09 (0.65–2.25)
Sex Male Female
– 1.00 1.35 (1.18–1.86)
Marital status Married/common law Separated/widowed/divorced Single
– 1.00 1.32 (0.96–1.89) 0.96 (0.58–1.96)
– 1.00 2.21 (1.38–3.31) n 0.94 (0.68–1.53)
Education Less than high school High school graduate Other post-secondary Post-secondary graduate
– 1.00 1.42 (1.11–2.23) n 1.25 (0.74–1.80) 1.05 (0.88–1.33)
– 1.00 1.35 (0.87–1.69) 1.13 (0.56–2.00) 0.95 (0.68–1.46)
Childhood foster Own parents Grandparents Other kinfolks
– 1.00 1.52 (1.22–2.86) 1.55 (1.35–3.25)
– 1.00 1.48 (1.15–2.31) n 1.35 (1.10–1.68) n
Rank Junior Senior Officer
– 1.00 0.85 (0.75–1.20) 0.56 (0.31–0.89)
Arm of the service Land Forces Navy Air Forces Missilery Forces Military Student Other Forces
– 1.00 0.98 (0.88–1.45) 1.15 (0.74–2.32) 1.29 (0.96–1.35) 1.32 (1.09–1.66)n 1.24 (0.65–2.95)
n n
n
n n
n
– 1.00 1.68 (1.31–2.27)
– 1.00 0.73 (0.61–1.06) 0.49 (0.12–0.85)
n
n
– 1.00 0.96 (0.76–1.53) 1.11 (0.86–1.46) 1.21 (0.67–2.01) 1.30 (1.04–1.85) n 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 quality of life We examined the differences in quality-of-life dimensions (SF-36 subscales) between the group with social anxiety disorder and the group without social anxiety disorder. Table 4 shows that the occurrence of social anxiety disorder was associated with poor scores on all dimensions of psychological health (po0.01).
In contrast, no significant correlations were found with physical health indices. Table 5 shows the patterns of the use of available resources by military personnel with past-year social anxiety disorder. Subjects most frequently reported seeking assistance from psychologists (20.1%). Psychiatrists' services were the next most commonly used, with 13.5% of individuals with past-year social anxiety disorder seeking this type of help. Other types of professional services were
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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Table 3 Morbidity of lifetime and past-year social anxiety disorder and other common psychiatric disorders. Diagnosis from CIDI
Lifetime social anxiety disorder
Psychiatric condition
n (%)
AOR (95% CI)
p
n (%)
AOR (95% CI)
p
Depression Panic attacks Panic disorder GAD PTSD Alcohol dependence
201 264 62 109 100 61
6.32 5.17 4.22 7.89 3.71 2.58
o 0.001 o 0.001 o 0.001 o 0.001 o 0.001 o 0.001
97 126 48 48 57 23
13.52 10.26 8.86 17.36 5.88 4.35
o 0.001 o 0.001 o 0.001 o 0.001 o 0.001 o 0.001
(31.0) (40.9) (10.4) (16.1) (15.0) (9.5)
Past-year social anxiety disorder
(4.87–7.11) (4.08–6.58) (3.32–5.38) (5.99–10.01) (3.01–4.62) (2.27–3.19)
(32.1) (37.0) (14.8) (13.8) (15.8) (6.1)
(9.57–19.63) (7.30–15.87) (5.07–12.79) (11.84–25.34) (3.87–8.47) (2.13–7.66)
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. SAD(þ ), n ¼355
SF-36 subscales Role-physical 0 1 2 3 4
Social functioning 0 1 2 3 Mental health
(39.72%) (12.39%) (12.68%) (22.25%) (12.96%)
3181 1732 1977 2039 2243
(28.47%) (15.50%) (17.70%) (18.25%) (20.08%)
150 75 67 63
(42.25%) (21.13%) (18.87%) (17.75%)
1166 983 1326 7697
(10.44%) (8.80%) (11.87%) (68.90%)
100 104 59 92
(28.17%) (29.30%) (16.62%) (25.92%)
1052 1854 1967 6299
(9.42%) (16.60%) (17.61%) (56.38%)
a
b
b
General health
141 44 45 79 46 a
Role-emotional 0 1 2 3
Vitality
SAD( ), n¼ 11,172 n ¼11,172
a
b
Physical functioning
b
Test of group differences χ2 (4, 11,523) ¼33.98 po 0.01
χ2 (3, 11,524)¼509.73 po 0.01
χ2 (3, 11,524)¼211.53 po 0.01
57.88 (22.3)
83.57 (25.5)
47.88 (31.5)
63.26 (39.0)
po 0.01 po 0.01
68.56 (18.9)
80.30 (34.6)
p¼ 0.043
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 Use of resources among military personnel with past-year social anxiety disorder. Type of resources
%
SE
Psychiatrist Psychologist Pluralistic counselor General practitioner Telephone helpline Internet support group In total
13.5 20.1 1.2 0.6 0.8 1.5 25.4
1.6 2.2 0.5 0.2 0.4 0.9 4.2
Note: respondents could select more than one resource as having been used in the past year; therefore, percentages are not expected to add up to 100. Note: the ‘n’ value was not presented due to small sizes, which may compromise respondent confidentiality.
used less often. Overall, only 25.4% of those with past-year social anxiety disorder sought professional service to deal with mental health problems. The use of other resources, such as internet support groups and telephone help lines, was much less common.
4. Discussion The present survey is the first epidemiology study of social fears and their correlates in the PLA, and it provides significant new information about the nature and impact of mental disorders in the active military. Owing to methodological differences, our findings may not be readily compared with those of Western studies. Nonetheless, our 12-month prevalence estimate (28.7%) of social fears is within the range found in Western studies (range: 24.1–38.6%) (Kessler et al., 1998; Wittchen et al., 1999a, 1999b; Sareen et al., 2007; Ruscio et al., 2008). The lifetime prevalence rate of 6.22%was also similar to a study on Canadian active military (Mather et al., 2010), to the European population (Fehm et al., 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 social fear. People with social anxiety disorder were characterized by fear and avoided the scrutiny of others. The concern in such situations is that the individual will say or do something that will result in embarrassment or humiliation. The most frequent social
Please cite this article as: Wang, H., et al., Social anxiety disorder in the Chinese military: Prevalence, comorbidities, impairment, and treatment-seeking. Psychiatry Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.07.063i
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fear was talking to people in authority or a person of a higher status, followed by performing/giving talk in front of an audience, and talking in a meeting or in class. These findings were in agreement with previous studies (Lee et al., 2009; Mather et al., 2010). There was an increase in the risk of social anxiety disorder in officers, military students, and separated/widowed/divorced people. The gender difference in the prevalence rate of social anxiety disorder was still significant even after adjusting for age and other potential confounding risk factors. Interestingly, this is the first time that childhood foster was identified as a risk factor for social anxiety disorder in the army. A main reason may be that there are more and more “left-behind” children in China. Except for childhood foster, social anxiety disorder in the PLA was found to share similar risk factors to other studies. In addition, higher education level was more related to social anxiety disorder in the army but not in nonmilitary people (Hsu and Alden, 2007; Lee et al., 2009; Osorio 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, psychotropic medication, having few friends, and having shy family members (Iancu et al., 2006). We observed a strong relationship between the likelihood of meeting criteria for PTSD and social anxiety disorder diagnosis. Specifically, many subjects with social anxiety disorder also had other psychiatric disorders, which is similar to other studies. For example, in an examination of over 1000 adult outpatients, the majority of patients with an ongoing principal diagnosis of social anxiety disorder had an additional Axis I diagnosis (Brown et al., 2001). Thus, our data concur with prior work, suggesting that only a small percentage of adults meet criteria for social anxiety disorder without the presence of other psychiatric conditions. We observed that panic attacks and depression were the two most frequent psychiatric conditions associated with social anxiety disorder in our subjects. Similar to nonmilitary samples (Schneier et al., 1992; Magee et al., 1996), social anxiety disorder was associated with alcohol dependence but not alcohol abuse. One interpretation is that subjects with social anxiety disorder frequently consume large quantities of alcohol that inevitably leads to dependence, but the discipline avoids excessive alcohol use. The finding that social anxiety disorder increased the odds of developing PTSD is of particular interest. This suggests that social anxiety disorder may be a risk factor for PTSD, but further investigation is needed. These findings further suggest that preventive measures could be taken among those with social anxiety disorder to reduce the chances that they develop PTSD or other mental disorders. There is an intimate relationship between social anxiety disorder and quality-of-life. As expected, respondents in the intermediate and high social fear groups reported significantly more physical symptoms than those in the low social fear group (Wittchen et al., 1999a, 1999b). Moreover, palpitations, blushing, voice shaking, and stammering significantly differentiated the intermediate and high social fear groups from the low social fear group. Being more socially noticeable, these physical symptoms may arouse more embarrassment that in turn exacerbates social anxiety. However, in this study, we only observed that social anxiety disorder was associated with poor scores on all dimensions of psychological health, and that no significant relations were found with physical health scores. One interpretation is that all subjects in this study had military training, and that their physical adaptive capability was better than nonmilitary people. Another possibility is that there is little personal or social value in light physical symptoms in cultural contexts with low levels of prevention focus. A previous study reported that Chinese individuals with social anxiety disorder exhibited a much lower treatment-seeking rate
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(8.7%) (Lee et al., 2009) than some Western communities (53.1%) (Mather et al., 2010), but not all (Sareen et al., 2007). Likewise, the present study showed a uniformly low rate (25.4%) of helpseeking, especially professional services. Our study found that over 74% of the sample had never sought treatment and that, of those, a further 40% cited avoidance factors as being the primary reason for this decision. This is consistent with previous studies suggesting that a large proportion of individuals meeting diagnostic criteria for an anxiety disorder are unwilling to seek help, largely due to psychological factors (e.g., their attitudes towards treatment) (Sareen et al., 2007; Vogel et al., 2007) as opposed to other factors (e.g., accessibility and mental health literacy) (Collins et al., 2004; Coles and Coleman, 2010). Furthermore, most patients in Western populations first seek help from a general practitioner (Sareen et al., 2007; Stein, 2009), while our population first sought help from psychological resources. 4.1. Interesting findings in the military related predictors of mental disorders The most significant finding of the present study is that childhood foster was significantly related with social anxiety disorder. We would considerate it as an evidence that the rapid development of the Chinese society promoted mass migration and the unprecedented tide of rural workers flooding, which led to many children growing up without living with their own parents. 4.2. Methodological considerations and limitations Some investigators of this study were unfamiliar with the established practice. Although diagnoses by clinicians are more valid, disarmament and personnel reform resulted in few psychiatrists working in the military, making it difficult to carry a survey by psychiatrists in the Chinese army.
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