Anxiety Disorder (DSM-IV-R)

 DIAGNOSTIC CRITERIA FOR SOCIAL PHOBIA

  1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.  The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.  Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
  2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.  Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
  3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
  4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared social or performance situations interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
  8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it (e.g., the fear is not stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa).

DIAGNOSTIC FEATURES

In feared social or performance situations, individuals with Social Phobia experience concerns about embarrassment and are afraid that others will judge them to be anxious, weak, "crazy," or stupid.  They may fear public speaking because of concern that others will notice their trembling hands or voice or they may experience extreme anxiety when conversing with other because of fear that they will appear inarticulate.  They may avoid eating, drinking, or writing in public because of a fear of being embarrassed by having others see their hands shake.  Individuals with Social Phobia almost always experience symptoms of anxiety (e.g., palpitations, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension, blushing, confusion) in the feared social situations, and, in severe cases, these symptoms may meet the criteria for a Panic Attack.  Blushing may be more typical of Social Phobia.


Adults with Social Phobia recognize that the fear is excessive or unreasonable, although this is not always the case in children.  The diagnosis for Social Phobia should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being called on in class when unprepared).


The person with Social Phobia typically will avoid the feared situations.  Less commonly, the person forces himself or herself to endure the social or performance situation, but experiences it with intense anxiety.  Marked anticipatory anxiety may also occur far in advance of upcoming social or public situations (e.g., worrying every day for several weeks before attending a social event).  There may be a vicious cycle of anticipatory anxiety leading to fearful cognition and anxiety symptoms in the feared situations, which leads to actual or perceived poor performances in the feared situations, which leads to embarrassment and increased anticipatory anxiety about the feared situations, and so on.

 

COURSE

Social Phobia typically has on onset in the mid-teems, sometimes emerging out of a childhood history of social inhibition or shyness.  Some individuals report onset in early childhood.  Onset may abruptly follow a stressful or humiliating experience, or it may be insidious.  The course of Social Phobia is often continuous.  Duration is frequently lifelong, although the disorder may attenuate in severity or remit during adulthood.  Severity of impairment may fluctuate with life stressors and demands.  For example, Social Phobia may diminish after a person with fear of dating marries and reemerge after death of a spouse.  A job promotion to a position requiring public speaking may result in the emergence of Social Phobia in someone who previously never needed to speak in public.

 

FAMILIAL PATTERN

Social Phobia appears to occur more frequently among first-degree biological relatives of those with the disorder compared with the general population.  Evidence for this is strongest for the Generalized subtype.

 

DIFFERENTIAL DIAGNOSIS

Individuals with both Panic Attacks and social avoidance sometimes present a potentially difficult diagnostic problem.  Prototypically, Panic Disorder With Agoraphobia  is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks.  Although social situations may be avoided in Panic Disorder due to the fear of being seen while having a Panic Attack, Panic Disorder is characterized by recurrent unexpected Panic Attacks that are not limited to social situations, and the diagnosis of Social Phobia is not made when the only social fear is of being seen while having a Panic Attack.  Prototypically, Social Phobia is characterized by the avoidance of social situations in the absence of recurrent unexpected Panic Attacks. 


Avoidance of situations because of a fear of possible humiliation is highly prominent in Social Phobia, but may also at times occur in Panic Disorder With Agoraphobia and Agoraphibia Without History of Panic Disorder.  The situations avoided in Social Phobia are limited to those involving possible scrutiny by other people.  Fears in Agoraphobia Without History of Panic Disorder typically involve characteristic clusters of situations that may or may not involve scrutiny by others (e.t., being alone outside the home or being home alone; being on a bridge or in an elevator; traveling in a bus, train, automobile, or airplane).  The role of a companion also may be useful in distinguishing Social Phobia from Agoraphobia (With or Without Panic Disorder).


Children with Separation Anxiety Disorder may avoid social settings due to concerns about being separated from their caretaker, concerns about being embarrassed by needing to leave prematurely to return home, or concerns about requiring the presence of a parent when it is not developmentally appropriate.