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The Diagnosis Of Social Phobia

تشخيص الرهاب الاجتماعي

الدكتور حسان المالح

director@hayatnafs.com

           فيما يلي عرض تفصيلي لتشخيص اضطراب الرهاب الاجتماعي وفقاً للتصنيف العالمي للاضطرابات النفسية والسلوكية العاشر ( 1992 ) والدليل الأمريكي التشخيصي والإحصائي للاضطرابات النفسية الرابع ( 1994 ) .

ويلي ذلك شرح وتفاصيل عن عدد من المقاييس والاستبيانات المستعملة في دراسة هذا الاضطراب .

 وأخيراً .. نقدم ترجمة بالعربية لمقياس قائمة الرهاب الاجتماعي [ SPIN تأليف كونور وآخرين ، وهو مقياس حديث ويفيد في الكشف عن حالات الرهاب الاجتماعي وفي استجابتها للعلاج .

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.
 

Rating scales for social anxiety

Evaluation Rating Scale Assessor
 
Clinical severity non-specific Clinical Global Impression Scale for Severity of Illness Clinician
  non-specific Clinical Global Improvement Scale Clinician
  non-specific Hamilton Rating Scale for Anxiety Clinician
  non-specific Hamilton Rating Scale for Depression Clinician
  specific Liebowitz Social Anxiety Scale Clinician
  specific Social Anxiety and Distress Scale Clinician
  specific Fear of Negative Evaluation Scale Patient
  specific Fear Questionnaire Patient
  specific Duke Brief Social Phobia Scale Patient
  specific Social Phobia and Anxiety Inventory Patient
  specific Social Phobia Inventory Patient
  specific Social Performance Scale Patient
  specific Social Interactional Anxiety scale Patient

Functional disability non-specific Sheehan Disability Scale Clinician
  non-specific Social and Occupational Functioning Assessment Scales Clinician
  non-specific World Health Organization Disability Assessment Schedule 2 Clinician
  non-specific Global Assessment Functioning Clinician
  non-specific Disability Profile Clinician
  specific Liebowitz Disability Self-rating Scale Patient
  specific Reilly Work Productivity and Impairment Questionnaire Patient

Quality of life   World Health Organization Quality of Life - 100 Patient
    World Health Organization Quality of Life - BREF Patient
    Short Form - 36 items Patient
    Short Form - 12 items Patient

Scales in bold are the most widely applied

 

Liebowitz Social Anxiety Scale (LSAS)

  • The LSAS has 24 items, of which 13 explore performance situations (P) and 11 examine social interaction situations (S).

1. Using a telephone in public P
2. Participating in a small group activity P
3. Eating in public places P
4. Drinking with others in public places P
5. Talking to people in authority S
6. Acting, performing, or giving a talk in front of an audience P
7. Going to a party S
8. Working while being observed P
9. Writing while being observed P
10. Calling someone you don't know very well S
11. Talking with people you don't know very well S
12. Meeting strangers S
13. Urinating in a public bathroom P
14. Entering a room when others are already seated P
15. Being the centre of attention S
16. Speaking up at a meeting P
17. Taking a test P
18. Expressing disagreement or disapproval to someone you don't know very well S
19. Looking at people you don't know very well in the eyes S
20. Giving a report to a group P
21. Trying to pick up someone P
22. Returning goods to a store S
23. Giving a party S
24. Resisting a high pressure salesperson S

  • Clinicians ask patients how they do or would react if confronted with each situation and use numerical scales to rate their fear or anxiety and avoidance.
Fear or anxiety Avoidance
1 = none 1 = never (0%)
2 = mild 2 = occasionally (1-33%)
3 = moderate 3 = often (34-67%)
4 = severe 4 = usually (68-100%)

 

  • Patients are then classified according to their total score as suffering from mild (<=51), moderate (52-81), or severe (>82) social anxiety.

Social Phobia Inventory (SPIN)

  • For SPIN, subjects are asked to self-complete a questionnaire with 17 items, rating on a five-point scale (not at all, a little bit, somewhat, very much, extremely) how much symptoms have bothered them during the past week.

1. I am afraid of people in authority
2. I am bothered by blushing in front of people
3. Parties and social events scare me
4. I avoid talking to people I don't know
5. Being criticised scares me a lot
6. Fear of embarrassment causes me to avoid doing things or speaking to people
7. Sweating in front of people causes me distress
8. I avoid going to parties
9. I avoid activities in which I am the centre of attention
10. Talking to strangers scares me
11. I avoid having to give speeches
12. I would do anything to avoid being criticised
13. Heart palpitations bother me when I am around people
14. I am afraid of doing things when people might be watching
15. Being embarrassed or looking stupid are among my worst fears
16. I avoid speaking to anyone in authority
17. Trembling or shaking in front of others is distressing to me

  • The clinician then scores the responses.

0 = not all

1 = a little bit

2 = somewhat

3 = very much

4 = extremely


 
  • Preliminary research with this instrument indicates that a cut-off total score of 19 distinguishes between subjects with and without social phobia. {See below)

The British Journal of Psychiatry (2000) 176: 379-386
© 2000
The Royal College of Psychiatrists

Psychometric properties of the Social Phobia Inventory (SPIN)

New self-rating scale

KATHRYN M. CONNOR, MD, JONATHAN R. T. DAVIDSON, MD, L. ERIK CHURCHILL, MS, ANDREW SHERWOOD, PhD and RICHARD H. WEISLER, MD

Department of Psychiatry and Behavioral Sciences, Duke University, Medical Center, Durham, NC

EDNA FOA, PhD

University of Pennsylvania

Declaration of interest Supported in part by Social Phobia Grant IR10-MH49339 to J.R.T.D. and by a grant from Smith Kline Beecham.

Correspondence: Kathryn M. Connor, MD, Box 3812, Duke University Medical Center, Durham, NC 27710, USA. Tel: (919) 684-5849; Fax: (919) 684-8866; e-mail: kathryn.connor@duke.edu

   ABSTRACT

 Background Of available self-rated social phobia scales, none assesses the spectrum of fear, avoidance, and physiological symptoms, all of which are clinically important. Because of this limitation, we developed the Social Phobia Inventory (SPIN).

Aims To establish psychometric validation of the SPIN.

Method Subjects from three clinical trials and two control groups were given the 17-item, self-rated SPIN. Validity was assessed against several established measures of social anxiety, global assessments of severity and improvement, and scales assessing physical health and disability.

Results Good test—retest reliability, internal consistency, convergent and divergent validity were obtained. A SPIN score of 19 distinguished between social phobia subjects and controls. The SPIN was responsive to change in symptoms over time and reflected different responses to active drugs v. placebo. Factorial analysis identified five factors.

Conclusions The SPIN demonstrates solid psychometric properties and shows promise as a measurement for the screening of, and treatment response to, social phobia.

( Full text is available.. http: //bjp.rcpsych.org/cgi/content/full/176/4/379

     

 قائمة الرهاب الاجتماعي ( Social Phobia Inventory )

في هذا الاستبيان يطلب من المفحوص أن يعطي تقديراً للأعراض وإزعاجها له خلال الأسبوع الماضي

 على مقياس من خمس درجات  (  لا أبداً ، قليلاً ، نوعاً ما ، كثيراً ، غالباً  )

 من خلال كل عبارة من العبارات 17 التالية :

   أخاف من الأشخاص في مراكز السلطة  

1

   أنزعج من احمرار وجهي أمام الآخرين  

2

 تخيفني الحفلات والمناسبات الاجتماعية

3

                       أتجنب الحديث إلى أشخاص غرباء لا أعرفهم  

4

النقد يخيفني جداً  

5

الخوف من الارتباك والإحراج يجعلني أتجنب القيام بأشياء أو التحدث مع الاخرين  

6

التعرق أمام الآخرين يسبب لي توتراً وانزعاجاً  

7

أتجنب الذهاب إلى الحفلات  

8

أتجنب النشاطات التي أكون فيها محط الانتباه  

9

يخيفني الحديث مع الغرباء  

10

أتجنب إلقاء كلمة  

11

أفعل أي شيء كي أتجنب الانتقاد  

12

يزعجني ازدياد ضربات قلبي عندما أكون بين الناس  

13

أخاف من القيام بأعمال معينة إذا كان الناس   ينظرون إلي

14

من أشد مخاوفي أن أكون محرجاً مرتبكاً أو أن أبدو غبياً  

15

أتجنب الحديث إلى أي شخص له سلطة  

16

تزعجني الرجفة أو الرعشة أمام الآخرين  

17

                            ثم يقوم الفاحص بوضع درجات لإجابات المفحوص على الشكل التالي :

                             لا أبداً = 0

                             قليلاً = 1

                             نوعاً ما = 2

                             كثيراً = 3

                             غالباً = 4

 

                            وتدل الدراسات المبدئية على أن الحصول على 19 درجة يفرق بين الحالات المرضية وغير المرضية .

 

                            

هذا الموضوع مأخوذ عن موقع القلق الاجتماعي  http://www.social-anxiety.org

والمجلة البريطانية للطب النفسي  http: //bjp.rcpsych.org/cgi/content/full/176/4/379

    ( ملاحظة : للمزيد من التفاصيل العلمية باللغة العربية حول الرهاب الاجتماعي

 يمكنك الاطلاع على كتابي الخوف الاجتماعي أو الخجل إضغط هنا )

تم النشر في 12/9/2003

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