Social Phobias

Social phobia (SP) is a condition characterised by an intense, irrational, persistent fear of being scrutinised or evaluated by others, with the patient anticipating humiliation or ridicule. The fear may involve most social interactions/situations where it is possible to be judged or be confronted with specific public performance. Anticipation of these situations is also experienced with uneasiness, distress or fear. The course of SP is that of a chronic, unremitting lifelong disease and secondary complications as depression, substance abuse (alcohol or tranquillisers) and suicide attempts may be associated with it, thus making the disorder severely disabling. SP is increasingly recognised as one of the more common anxiety disorders.

Only with recent largescale epidemiological studies of psychiatric disorders has the true prevalence of SP been recognised. Lifetime prevalence has been reported to vary between 2% and 4% in most epidemiological studies with other epidemiological surveys reporting rates even three times as higher. SP is a relatively recent diagnosis as it was first described by Marks and Gelder as‘‘fears of eating, drinking, shaking, speaking, writing, and so on in presence of other people’’, the central feature being the fear of seeming ridiculous to others. SP has been found to differ from panic disorder (PD) with or without agoraphobia and from other phobias as regards age of onset, sex occurrence, response to provocation challenges, course and response to treatment. Marks and Gelder’s definition included patients with specific social fears and those with more generalised forms of social anxiety (i.e. fears of initiating conversations, meeting new people, members of opposite sex, people in authority).

DSM-III described SP as a circumscribed phobia, involving anxiety about a situation in which the individual is exposed to possible scrutiny by others, implying that patients with multiple fears or more generalised SP are rare or should be included in other diagnostic categories; the diagnosis of SP had to be excluded if the criteria for avoidant personality disorder were fulfilled. Because of the lack of empirical bases, the rule of exclusion of SP in the presence of the axis II disorder was omitted in DSM III-R and a generalised type of SP was included.

TheDSM III-R criteria for SP and avoidant personality disorder have a high degree of similarity and overlap. DSM-IV, that have not changed markedly from those found in DSM III-R, did not clarify much this distinction. In general, APD should be characterised by the absence of intense fears reactions with a much milder, less pervasive pattern of discomfort in social situations in which the patients feel they are exposed to evaluation or scrutiny. As a rule, however, SP and APD coexist in the majority of cases complaining of social anxiety.

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