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Social Phobias |
Overcoming Anxiety (Home) > Social Phobias > Differential Diagnosis Differential Diagnosis: Headache and Anxiety DisorderAvoidant personality disorder appears to imply more severe social dysfunction and therefore it could be a severe variant of GSP. Nevertheless, these disorders are defined differently: SP in terms of phobic anxiety and APD in terms of social dysfunction. Further research is needed to distinguish them. From a clinical point of view, there is considerable overlap in the symptomatology of SP and panic disorder with or without agoraphobia, since the anxiety reaction in social phobics may be experienced sometimes as a full-blown panic attack. However, the nature of the fear, feared situations, prevalent somatic symptoms, social-demographic data, biological and treatment studies are useful to distinguish between these disorders. The essential feature of agoraphobia is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic-like symptoms (DSM-IV). Even if most agoraphobics also express fears of losing control, going insane, embarrassing themselves and others, in SP the fear of negative evaluation is central and associated with concerns about embarrassment and humiliation in front of others. Consequently, whereas patients with panic disorder and agoraphobia have panic attacks in a variety of non-social situations (tunnels, supermarkets, subways, bridges) and are comforted by the presence of a familiar figure when experiencing anxiety, in social phobics panic attacks are bound or predisposed to occur in only the social situations feared by the patients, and the subjects feel more comfortable if they can be alone and eschew contact with others. In SP patients, differently from agoraphobic patients, the avoided situations stand out quickly and avoidance does not extend, but remain constant. In addition, panic attacks in patients with panic disorder with or without agoraphobia can occur at any time in any setting, even awakening the patient from sleep and are accompanied by severe, acute, bodily symptoms: circulatory, respiratory, neurological-like, sweating, nausea or abdominal distress, chill or hot flushes. Patients with agoraphobia and SP also differ with respect to the type of somatic symptoms. Individuals with agoraphobia are more likely to report problems with limb weakness, feeling faint or dizzy, breathing problems, fear of passing out, and tinnitus, whereas individuals with SP are more likely to complain of blushing and muscle twitches. The kind of phobic stimuli may therefore be associated with a different somatic symptom pattern: shortness of breath is a common symptom in panic attacks associated with agoraphobia, whereas blushing is common in panics related to social or performance anxiety. On an epidemiological point of view, compared with agoraphobia, SP is less prevalent (in the community as well as the clinic), is about equally represented among males and females who seek treatment for the disturbance (in comparison to a preponderance of females among agoraphobics), and has an earlier age of onset. Results of biological challenge and treatment studies suggest that SP and panic disorder/agoraphobia may also be characterised by different pathophysiological mechanisms. Social phobics appear distinct from schizoid patients. Although both may avoid social interaction, by definition, the social phobics desire social contact, but are blocked by anxiety, while schizoid patients lack interest in social interaction. Clinical observations suggest that patients with Body Dysmorphic Disorder (BDD) resemble those with SP in their tendency to feel ashamed, defective, and socially anxious, as well as in their fear of being embarrassed, ridiculed, and isolated. Patients with body dysmorphic disorder are substantially more concerned about their body’s appearance and perceived ugliness than about problems of performance in a social setting. Atypical depression, with its marked anxiety and rejection-sensitivity, overlaps with SP. However, the presence of reversed vegetative symptoms of hypersomnia and hyperphagia and an unusual heaviness sometimes described as ‘‘leaden paralysis’’ goes well beyond the symptoms of typical SP and these symptoms are properly classified as a depressive disorder. The distinction between SP and shyness raises the question of whether these concepts represent different aspects of one united domain of interpersonal difficulties. In 1910 Hartemberg described several forms of social anxiety under the generic term of shyness (timidity, performance anxiety, personality disorders). The features used to define shyness, such as impairment in social performances, inhibition of adequate behaviour, avoidance of interpersonal situations and autonomic symptoms are the same as SP. People suffering from dispositional shyness and those with a diagnosis of SP seem to make similar somatic responses to social situations and to have similar fears of negative evaluations. Social phobics, however, seem to avoid social settings and to suffer from more impaired day-to-day functioning than those who are shy. Besides, the prevalence of SP is estimated as between 3 and 13%, while the prevalence of shyness is around 40%. Shyness, being a stable early onset characteristic, is often considered a personality or temperamental feature. Its considerable similarity with SP and APD (avoidant personality disorder) suggests a certain overlap, and it is possible that those terms describe different degrees of severity of the same condition. However, in clinical experience, some patients with SP do not report feeling uneasy in interpersonal relationships other than the specific feared situation.
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