342 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Gender and Cross- Cultural Differences
Unlike the other anxiety disorders, the gender ratio for social phobia is not as highly
skewed toward women. There is an approximate 3:2 ratio of women to men with social
phobia. In the NCS the lifetime prevalence for women was 15% and for men 11.1%
(Kessler et al., 1994). However, Rapee (1995b) notes that an equal number of men and
women seek treatment for social phobia, although nonclinical questionnaire studies
suggest women may feel greater social anxiety and shyness than men (e.g., Wittchen et
al., 1999). Cross- cultural differences may also be apparent in the gender ratio for social
phobia. In a study conducted on a Turkish sample of 87 individuals with DSM-III-R
social phobia, 78.2% were men (Gökalp et al., 2001).
Cross- national differences have also been reported in the prevalence of DSM-III
or DSM-IV social phobia. In the Cross- National Epidemiological Surveys there was a
fourfold increase of social phobia in English- speaking Western countries compared to
East Asian countries like Taiwan and South Korea (see Chapman, Mannuzza, & Fyer,
1995). The authors question whether this reflects real differences in the rates of social
phobia across cultures. They note that the interview questions may have lacked cultural
relevance outside Western countries. Also there are conditions analogous to social pho-
bia that are specific to certain Asian countries that were not included in the survey such
as “taijin kyofu-sho” (TKS) in Japan, which is a persistent and irrational fear of caus-
ing offense, embarrassment, or harm to others because of some personal inadequacy or
shortcoming (Chapman et al., 1995).
Even within Western countries where rates of social phobia may be quite similar,
the clinical presentation of the disorder can be affected by cultural factors. For example,
a study that compared social phobia in American, Swedish, and Australian samples
found that the Swedish sample was significantly more fearful of eating/drinking in pub-
lic, writing in public, meetings, and speaking to authority figures (Heimberg, Makris,
Juster, Öst, & Rapee, 1997). Thus social phobia may be found in most countries around
the world but the social concerns, symptom presentation, and even threshold for disor-
der may vary across cultures (Hofmann & Barlow, 2002; Rapee & Spence, 2004). As
well, the mediating variables for social anxiety may differ between cultures. For exam-
ple, shame has a stronger mediating role in social anxiety for Chinese than American
samples (Zhong et al., 2008).
Age of Onset and Course
Social phobia typically begins in early to mid- adolescence which gives it a later onset
than specific phobias but an earlier onset than panic disorder (Öst, 1987b; Rapee,
1995a). In the NCS-R, 13 years old was the median age of onset for social phobia which
was substantially younger than the onset age for panic disorder, GAD, PTSD, and OCD
(Kessler, Berglund, et al., 2005). In fact many individuals with social phobia report a
lifelong struggle, with 50–80% reporting an onset of the disorder in childhood (Otto et
al., 2001; Stemberger, Turner, Beidel, & Calhoun, 1995). Early onset is associated with
a more chronic and severe course of the disorder (Beidel & Turner, 2007).
It is commonly believed that untreated social phobia takes a chronic and unremit-
ting course (Beidel & Turner, 2007; Hofmann & Barlow, 2002; Rapee, 1995b). This
appears to be supported by a number of longitudinal studies in which the majority of