MENTAL HEALTH ISSUES IN RURAL AND URBAN POPULATION IN GUJRANWALA PAKISTAN, A COMPARATIVE ANALYSIS

Mental Health includes emotional, and social well-being and it centers, perception of a person, how an individual deals with the demands of life, and what he feels about problems of his life. WHO and CD defines mental health as “Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community ”(1). Mental health is not just that a person never diagnosed with any mental disorder. Most common form of mental health issue is SAD, social anxiety disorder well known as “ Social Phobia” since, 1960s (2). It is described as a protracted fear of receiving criticism from others and a propensity to avoid participation in social activities along with extreme fear of embarrassment, shame, or rejection (3). SAD can be extremely upsetting for  learning, working, establishing personal connections and is more frequent during adolescence which can get better  with advancement in age (4). Approximately  13% of population experiencing social phobia, which might be both specific or generalized (5) worldwide. Prevalence of SAD 12% have been reported  (6) as compared to lifetime prevalence of GAD 6%, panic disorder 5%, post-traumatic stress disorder (PTSD) 7% and obsessive-compulsive disorder (OCD) 2%. According to National Comorbidity Survey, (SAD) is the 3rd most prevalent psychiatric ailment, following major depression (MD) and alcoholism (7) and it is also greater than the cumulative prevalence of the  (rheumatoid arthritis  (RA),  Crohn's disease, ulcerative colitis, systemic lupus erythematosus, diabetes mellitus type I Type 1 DM, multiple sclerosis, uveitis, hypothyroid (8).Differential diagnosis of SAD includes  atypical depression, agoraphobia, panic disorder, and body dysmorphic disorder (9).  SAD prevalence rates for children and adolescents are comparable to those for adults. Social anxiety disorder affects women more frequently than men (10).

Risk factors of SAD include youth, children of low-income families, and citizens of the United States (11). Though it is mostly linked by hesitant nervous behavior in particular situations but is not a specific marker of SAD in young people (12). Various personality traits and personal experiences may affect social comfort levels of a person during SAD (13).Emotional and behavioral changes like nervousness about any situations in which person might be negatively judged, might be worry about embarrassing or humiliating himself. Patient can have strong aversion to interacting with or having a conversation with strangers, fear that others will notice him to be anxious, and suspicious about outward manifestations of his situation like blushing, sweating, trembling, or having a shaky voice (14). Similarly skipping activities like speaking to people out of fear of embarrassment, ignore activity or situation where patient might be center of attention. Critically judgement of patient himself about shortcomings after any social interactions and expect worst possible consequences from a bad experience during a social situation (15). Flushing, shaking, sweating, nausea, an upset stomach, trouble breathing, dizziness or lightheadedness, and the absence of mind are all physical signs of SAD (16). With the passage of time, SAD symptoms may get worsen due to a lot of stress and expectations in patient's life. Anxiety is likely to long Laster if not get better at time after therapy (17).

Social anxiety is more widespread than previously believed on a global scale, with 36% of respondents meeting the criterion for having (SAD). Depending on an individual's age, country of origin, occupational setting, degree of education, and where they lived—urban or rural—social anxiety symptoms varied in frequency and severity (18).

Epidemiological research showed highest SAD ratio in USA 7% than Korea 0.6%, China 0.2%, Japan 0.8%. Women are more likely than males to suffer from SAD (19). SAD is commonly manifests at a young age of 20 in 80% of youngsters and might be at age of 11year in 50% (20). It may be linked to more complicated mental disease and drug dependence later on in life (21). Neuro-imaging diagnostic studies pointed towards amygdala and insula with higher activity during SAD along with fundamental characteristics of personality trait neuroticism to uncover risk loci (22).According to a British epidemiological survey (23), 0.32 % children and adolescents of 5 and 15 suffered from SAD, which might be more problematic than post-traumatic stress disorder (PTSD), obsessional compulsive disorder (OCD), and panic disorder while it was less common than separation anxiety disorder, specific phobia, and generalized anxiety disorder. Author found that males had a higher rate of SAD than females, with slight increase with age. Many other studies found same results in children aged 9-11 years (24), and 14-17 years (25). In another study, author focused on role of obesity in SAD patients stating that significantly greater seasonal alterations in appetite and weight patterns in patients with SAD than in normal individuals. It was suggested that SAD may offers an opportunity to recognize reversible obesity in humans (26). In a survey conducted in different countries more than 1/3rd respondents met the criteria for (SAD), making it the most common anxiety disorder globally. However, according to authors, age, country, employment status, education level, and urban or rural setting can play a role in the prevalence and severity of social anxiety symptoms (27).