Diagnostic issues

DSM-III originally described social phobia as a fear of embarrassment, humiliation, and scrutiny by others in one or two specific performance situations. It also stated that social phobia rarely led to substantial impairment. However, research and clinical experience suggest that individuals whose fears are limited in this way represent a minority of persons with social phobia who present for treatment. More commonly, those presenting for treatment endorse multiple fears and significant impairment/5 In recognition of the heterogeneity of persons with social phobia, DSM-IIIR (1..2) and DSM-IV include subtypes of social phobia. The generalized type is specified when 'most social situations' are feared. Persons whose fears do not extend to most social situations are grouped together into the non-generalized subtype of social phobia. While these criteria are ambiguous, persons with generalized and non-generalized social phobia differ on several dimensions, including symptom severity, functional impairment/13 and physiological symptoms when exposed to feared situations/1, I4) However, conclusive differences between subtypes in the course and response to treatment remain to be demonstrated/1. I6

Like social phobia, avoidant personality disorder (APD) first appeared in DSM-III and has undergone significant revision. While DSM-III regarded social phobia as an irrational fear of a limited number of performance situations, it regarded APD as an instance of severe interpersonal anxiety. Furthermore, the presence of APD pre-empted a diagnosis of social phobia. Later, DSM-IIIR allowed an individual to receive concurrent diagnoses of social phobia and APD, and the criteria for APD became more similar to those of social phobia. The core disturbance of APD was changed to an extreme fear of negative evaluation rather than discomfort in interpersonal relationships. (17) Changes to the criteria for APD, as well as the evolution of the social phobia criteria, have led researchers to question whether the two categories represent distinct disorders or whether they differ only in degree. Indeed, research supports the position that social phobia and APD belong on a continuum that is artificially divided at the boundary between Axes I and II. (17> Individuals with APD almost always have social phobia, while many individuals with social phobia do not meet the criteria for APD. Individuals with generalized social phobia (median = 58 per cent) are more likely than individuals with non-generalized social phobia (median = 18 per cent) to meet the criteria for APD.(1.7> Many investigators have concluded that the co-occurrence of generalized social phobia and APD describes those persons with the most severe social phobia and the poorest global functioning. (18>

The DSM-IV task force considered other refinements to the criteria of social phobia. The parenthetical name 'social anxiety disorder' was added to acknowledge the significant impairment associated with social phobia and its differentiation from specific phobia. The criteria were also modified to include features specific to children/11.) There must be evidence that children are capable of forming social relationships, and anxiety must be evident in peer relationships. It is also acknowledged that children may manifest their anxiety differently than adults: they may cry, throw tantrums, freeze, or shrink from interactions with strangers, and they may not acknowledge that their fears are irrational. Also, social anxiety may develop as a result of some medical conditions. For example, persons may become excessively anxious or avoid social situations because of obesity, acne, benign essential tremor, stuttering, or Parkinson's disease. These conditions are not considered exemplars of social phobia in DSM-IV because anxiety developed secondary to the medical condition. Instead, they are assigned to the category 'anxiety disorder not otherwise specified'. However, persons who experience secondary social anxiety are often responsive to pharmacological or cognitive-behavioural treatments that demonstrate efficacy for social phobia.(1.9) While there was substantial discussion about this issue in the DSM-IV workgroup, this loophole in the diagnostic criteria was not closed.

Overcome Shyness 101

Overcome Shyness 101

You can find out step by step what you need to do to overcome the feeling of being shy. There are a vast number of ways that you can stop feeling shy all of the time and start enjoying your life. You can take these options one step at a time so that you gradually stop feeling shy and start feeling more confident in yourself, enjoying every aspect of your life. You can learn how to not be shy and start to become much more confident and outgoing with this book.

Get My Free Ebook


Post a comment