Social Phobia Diagnosis

In 1970, Marks was the first to discuss SP as a clinical syndrome distinct from other anxiety disorders. As explained before, SP was not officially recognised as a diagnostic entity until the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorder. The original DSM-III description of SP emphasised the difficulty for the clinician in identifying SP from other psychiatric disorders. SP was defined ‘‘a persistent, irrational fear of, and compelling desire to avoid a situation, in which the individual is exposed to possible scrutiny by others and fears that he or she may act in a way that will be humiliating or embarrassing’’. Anticipatory anxiety and avoidance occur when the individual is under scrutiny while speaking or performing publicly, eating with others, writing in public, or using public bathrooms. In the revised DSM-III, the pervasiveness of impairment across situations was explicitly recognised by the creation of a generalised subtype (GSP), in which distress is found in all or most social situation.

DSM-IV does not change much and the difficulty in diagnosing SP is implicitly expressed by the fact that there are two exclusion criteria where the sentence ‘‘not better accounted for by’’ is reported. Apart from inclusion of physical symptoms (as blushing, tremor, nausea) and the specifica- tion that the fear of scrutiny is associated with situations involving comparatively small groups of people, ICD-10 is no more precise or helpful to the diagnosis than DSM-IV in defining the criteria for SP.

Basically, the problems in the diagnosis of SP are the following:

1. The difficulty of distinguishing between shyness and SP, since quantitative rather than qualitative criteria are often used; moreover the level at which shyness is considered acceptable, or even culturally desirable, varies in different cultures and countries. In most languages, the word ‘‘shameless’’ represent an insult.
2. In the epidemiological studies uneasiness, distress and avoidance of social situations were considered important diagnostic elements; however, these may be due to lack of interest and motivation (as may be the case with several disorders, e.g. schizoid disorder, depression, schizophrenia) or difficulty in dealing with the situation. The latter, in turn, may be due to factors related to psychopathological conditions other than the fear of being under scrutiny (e.g. psychotic suspiciousness, depression, body dysmorphic disorder, eating disorders). In other cases the uneasiness and the avoidance may be due to the fact that the situation is actually too demanding for the capacities of the individual. Finally, the explication of inability in social situations is solely possible when the subject requires to deal with such situations. The phobia of speaking in public, for instance, may be a serious problem for a teacher, but may not be felt as such in a nun.
3. The boundaries between generalised SP (GSP) and APD (avoidant personality disorder) are uncertain and it is unclear if they represent qualitatively distinct nosological entities or whether they reflect quantitative variants of essentially the same spectrum of psychopatology. DSM-IV recognised APD as ‘‘a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation’’ that begins at least by early adulthood.

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