The two main classification systems for
mental disorders, ICD-10 (1992; F40.1 Social Phobias) and DSM-IV
(1994; Social Phobia [Social Anxiety Disorder]), recognise social
anxiety disorder/social phobia. Both describe the essential features
to be a fear of scrutiny by other people in social situations, a
fear of criticism or humiliation, and avoidance of feared
situations. The condition may be diffuse/generalised, i.e. involving
almost all social contacts, or discrete/non-generalised, i.e.
restricted to specific social activities or performance situations.
ICD-10
The ICD-10 Classification of Mental and
Behavioural Disorders. World Health Organization, Geneva, 1992.
F40.1 Social Phobias.
ICD-10 describes social phobia as centred
around a fear of scrutiny by other people in comparatively small
groups (as opposed to crowds), usually leading to avoidance of
social situations. The fear may be discrete, i.e. restricted
to particular situations such as eating or speaking in public and
encounters with the opposite sex, or diffuse, i.e. involving
almost all social situations outside the family circle.
Social phobia is usually associated with
low self-esteem and fear of criticism. They may present as a
complaint of blushing, hand tremor, nausea, urgency of micturation,
the individual sometimes being convinced that one of these secondary
manifestations of anxiety is the primary problem. A fear of vomiting
in public may be present.
For a definite diagnosis of a social
phobia, according to the ICD-10 classification, three criteria must
be met:
1- The psychological,
behavioural, or autonomic symptoms are primarily manifestations of
anxiety and not secondary to other symptoms, such as delusions or
obsessional thoughts
2- The symptoms are restricted
to or predominate in particular social situations
3- The phobic situation is
avoided whenever possible
Social phobia may progress to panic
attacks. Avoidance is often marked and in some cases may lead to
complete social isolation.
Differential diagnosis
Agarophobia and depressive disorders are
often prominent and may contribute to the individual becoming
'housebound'. If the distinction between social phobia and
agoraphobia is difficult, ICD-10 states that precedence should be
given to agoraphobia. A depressive diagnosis should not be made
unless a full depressive syndrome can be identified clearly.
DSM-IV
Diagnostic and Statistical Manual of
Mental Disorders, Fourth edition, Washington, DC, American
Psychiatric Association, 1994. 300.23 Social Phobia (Social Anxiety
Disorder).
DSM-IV describes social phobia (social
anxiety disorder) as a marked and persistent fear of one or more
social or performance situations in which the individual is exposed
to unfamiliar people or to possible scrutiny by others. The
individual fears acting in a way (or showing anxiety symptoms) that
will be humiliating or embarrassing.
Five criteria should be considered for a
definite diagnosis according to DSM-IV.
1- Exposure to the feared situations provokes
anxiety and sometimes a panic attack
2- The individual recognises that the fear
is excessive or unreasonable
3- The feared situations are avoided or else
endured with intense anxiety or distress
4- The avoidance, anxious anticipation, or
distress interferes with the individual's normal routine,
occupational functioning, or social activities or relationships, or
there is marked distress about having the phobia
5- In individuals under the age of 18 years,
the duration is at least six months
If the fears include most social
situations, the social phobia is described as generalised.
Differential diagnosis
In DSM-IV, for a diagnosis of social
phobia, the fear or avoidance must not be due to the direct
physiological effects of a substance or a general medical condition.
In addition, they should not be better accounted for by another
mental disorder such as panic disorder (with or without
agoraphobia), separation anxiety disorder, body dysmorphic disorder,
a pervasive developmental disorder, or schizoid personality
disorder.
If a general condition or other mental
disorder is present, the fear should not be unrelated to it, e.g.
the fear must not be of stuttering, trembling in Parkinson's
disease, or exhibiting abnormal eating behaviour in anorexia nervosa
or bulimia nervosa.
Differences between ICD-10 and DSM-IV
Although there is broad agreement between
the ICD-10 and DSM-IV diagnostic criteria, the essential difference
relates to the differential diagnosis of social anxiety disorder and
agoraphobia.
ICD-10 suggests that if the distinction
between social phobia and agoraphobia is difficult, precedence
should be given to agoraphobia, whereas DSM-IV differentiates
between the two conditions on the basis of fear of social
situations. In other words, if the fear is of being scrutinised by
others in a particular social situation or set of social situations,
then the best diagnosis is social phobia. On the other hand, if the
concern is about having a panic attack, or becoming incapacitated
(e.g. fainting) in a situation or a set of situations, then the best
diagnosis is agoraphobia.
Rating scales
A number of
rating scales
can be used to facilitate diagnosis and assessment of clinical
improvement in subjects with social anxiety.
The rating scales can be categorised as
evaluating:
* clinical severity;
* functional disability;
and
* quality of life.
Clinical severity and functional disability
scales can be further distinguished as:
* non-specific, i.e.
designed to evaluate a wide range of anxiety disorders; or
* specific, i.e.
designed to examine only social anxiety; and
* clinician-rated or
patient self-rated.
The most widely applied rating scales for
assessing social anxiety are:
* the Clinical Global
Impression Scale for Severity of Illness (CGI-SI), for non-specific
assessment of clinical severity;
* the
Liebowitz Social Anxiety Scale
(LSAS), for specific assessment of clinical severity; and
* the Sheehan
Disability Scale, for non-specific assessment of associated
functional disability.
Although highly useful, the LSAS rating
scale has some limitations: its psychometric properties have not
been extensively tested in clinical studies (although studies are
ongoing) and it does not examine physiological symptoms, such as
heart palpitations and blushing (Liebowitz,
1987).
The Social Phobia and Anxiety Inventory (SPAI),
an empirically derived self-report inventory, was developed as a
specific measure of social phobia (Beidel
et al, 1989) and is also available
in a version suitable for use in children (SPAI-C). It is probably
the rating scale which has been most well-studied psychometrically
to date. However, it has been used more in cognitive behavioural
studies than psychopharmacological studies.
The
Social Phobia Inventory
(SPIN) is a new specific self-rating scale which assesses the
spectrum of fear, avoidance, and physiological symptoms of social
anxiety (Connor et al,
in preparation).
References
Beidel DC, Borden JW, Turner
SM, Jacob RG. The Social Phobia and Anxiety Inventory: concurrent
validity with a clinic sample. Behav Res Ther 1989; 27: 573-576.
Connor KM, Davidson JRT,
Churchill E, et al. Psychometric properties of the Social Phobia
Inventory (SPIN): a new self-rating scale. In preparation.
Diagnostic and Statistical Manual of Mental
Disorders, Fourth edition, American Psychiatric Association,
Washington DC, 1994. 300.23 Social Phobia (Social Anxiety Disorder).
ICD-10 Classification of Mental and
Behavioural Disorders. World Health Organization, Geneva, 1992.
F40.1 Social Phobias.
Liebowitz MR. Social phobia.
Mod Probl Pharmacopsychiatry 1987; 22: 141-73.
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