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How are Social Phobias Diagnosed?

written by: Mercedes Hamshar • edited by: Jacqueline Chinappi • updated: 10/14/2010

Diagnosing social phobias can be more complicated than it appears. Although one of the most common anxiety disorders to affect the general population, social phobia is often under or mis-diagnosed due to its similarity and comorbidity with other disorders.

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    Social phobia is an anxiety disorder characterized by clinically significant (i.e above the norm of the general population) anxiety reactions and extreme discomfort occurring in anticipation to or upon exposure to social settings, including performance and test situations. Cases of social phobia vary in severity and often has detrimental effects on one's social and/or career development. Epidemiological surveys report that social phobia is one of the most common anxiety disorders to affect the general population, and suggest a prevalence rate of 13.3%. However, it is also thought that many cases of the disorder go unrecognized and that most cases begin in childhood or adolescence but are not reported until much later in life due primarily to the nature of the disorder. This presents challenges for diagnosing social phobias.

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    The Diagnosis

    Conducting a diagnosis for social phobia primarily takes the same form as diagnosing all other mental disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV), assuming the practitioner in question uses the DSM-IV. A mental health practitioner must interview their patient to ascertain whether they meet the diagnostic criteria for social phobia set out in DSM-IV and ascertain which typical social fears cause anxiety for this person.

    To receive a diagnosis of social phobia a person must:

    • Show a marked, persistent fear triggered by exposure to unfamiliar people or social scrutiny
    • Experience intense anxiety about being embarrassed or humiliated when exposed to the trigger
    • Realise that their fear is unrealistic and irrational
    • Avoid trigger situations or endure situations while suffering intense anxiety.

    Once a practitioner is confident that a person meets the diagnostic criteria for social phobia they go on to diagnose the type of social phobia the person in question has; generalized or non-generalized. Generalized social phobia, the most debilitating form, means that the person fears most social situations and interactions. Non-generalized social phobia means that the person fears specific social situations, usually public performing or speaking, where judgement is inevitable.

    As previously mentioned, cases of social phobia vary in severity. Once a preliminary diagnosis of social phobia has been made, further measures may be taken to gain insight into the severity of the particular case of social phobia. Schneier et al (1994) developed a clinical instrument to estimate disability in social phobia, named the Disability Profile. It measures the level of impairment in areas of the patient's life, namely; education, employment, family relationships, marriage/romantic relationships, friendship/social network and other interests.

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    Problems With Diagnosing Social Phobia

    Although the process of diagnosing social phobias appears fairly simple, there are several factors that can make the process of diagnosis difficult. First, consistent diagnostic thresholds are important. Having diagnostic thresholds too low can mean that 'normal' people who are considerably shy may be diagnosed with social phobia. Having diagnostic thresholds too high can mean that only particularly severe cases of social phobia are detected.

    Mistaken diagnosis is also a problem in diagnosing social phobia. Social phobia can easily be confused with agoraphobia with and without panic attacks if a practitioner is not thorough enough. People with agoraphobia also present with anxiety about social situations. However, their anxiety is primarily about fear of being unable to escape social situations, not about social situations themselves. It is important that a practitioner pays careful attnention to the main clinical feature of social phobia; fear of scrutiny and humiliation in social situations.

    Finally, comorbidity is another problem in diagnosing social phobia and most other disorders. Like all anxiety disorders, social phobia is highly comorbid with other disorders such as simple phobias, panic disorder with agoraphobia, alcohol abuse, major depression, dysthmia, generalised anxiety disorder and obsessive compulsive disorder. Therefore, cases do not often appear as one would expect based on the diagnostic criteria for social phobia. Practitioners must separate the different symptoms that patients present with in order to be able diagnose the different disorders. Comorbidity can greatly change the course of a disorder and effect its treatment. For instance, it has been recognised that social phobia that is comorbid with major depression leads to frequent suicidal ideation and more suicide attempts than expected, and therefore that it is clearly more severe than 'pure' social phobia. Similarly, it is thought that 15% of those with social phobia have had a drinking problem. Alcohol abuse usually needs to be treated before people can benefit from treatment for social phobia. While alcohol is being abused the symptoms of social phobia are often obscured, and can be mistaken for withdrawal symptoms when alcohol is given up.

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    References

    American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Health Disorders. USA: American Psychiatric Association.

    Brunello, N., den Boer, J.A., Judd, L.L., Kasper, S., Kelsey, J.E., Lader, M., Lecrubier, Y. Lepine, J.P., Lydiard, R.B., Mendlewicz, J., Montogomery, S.A., Racagni, G., Stein, M.B. & Wittchen, H.U. (2000) Social phobia: diagnosis and epidemiology, neurobiology and pharmacology, comorbidity and treatment. Journal of Affective Disorders, 60, 61-74.

    Schneier, F.R., Heckelman, L.R., Garfinkel, R., Campeas, R., Fallon, B.A., Gitow, A., Street, L., Del Bene, D., Liebowitz, M.R. (1994) Functional impairment in social phobia. Journal of Clinical Psychiatry, 55, 322-331.