There are few individuals who have not, at some time in their lives, felt anxious and self-conscious when they have been the focus of others' attention, such as when making an oral presentation in school or conversing at a party. It is perhaps because of the universal nature of such experiences that recognition of social phobia as a significant mental health problem has been impeded. Although the disorder was first described1 almost 30 years ago, most of what we know about social phobia has been learned from research conducted in the past decade. Not only has social phobia not been accorded the attention that other less prevalent psychiatric problems have received from researchers, but it appears that it has also been frequently overlooked in clinical practice. In this article, we review the clinical features and presentation of social phobia and provide an overview of recent findings pertaining to the epidemiology of the disorder.
WHAT IS SOCIAL PHOBIA?
Social phobia is one of several anxiety disorders specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).2 It is characterized by excessive fear of situations in which an individual is exposed to unfamiliar people or to the scrutiny of others. The underlying basis of the disorder is a fear of being embarrassed or evaluated negatively by others. Concerns in social situations typically focus on saying or doing something embarrassing or displaying anxiety symptoms, such as sweating or shaking, which will be noticeable to others. Efforts to minimize distress typically lead to avoidance of feared situations and thereby result in impairment in academic, occupational, and social functioning.
In order to illustrate some of the essential features of social phobia, a case study describing an individual with pervasive social anxiety is presented.
Janet was a 26-year-old, single woman who was employed part-time as a veterinary assistant. She presented to an anxiety disorders clinic complaining of anxiety symptoms that had started in elementary school. She recalled that, as a child, her anxiety became so intense before performing in piano recitals that she would vomit. She described herself as being a "loner" in high school and indicated that she usually avoided going into the cafeteria at lunch and never attended a school dance. Upon graduating from high school, she wanted to study music at university, but was never able to enroll because of anxiety about performing in front of others.
At the time of the assessment, Janet reported intense fear of a number of social situations, including eating and writing in front of others, speaking in public, attending social gatherings, dating, and dealing with authority figures. In these situations, she was concerned that people were evaluating or staring at her, and that she might make a fool of herself by doing something inappropriate. For instance, she felt extremely anxious when eating in restaurants because she was afraid that her hand would shake and coffee would spill on her clothing. As a result of her fear, she avoided many situations in which she would be the focus of attention or have to speak to others, including eating in restaurants, signing checks in front of cashiers, dating, attending parties, and approaching her employer to discuss job-related concerns.
DSM-IV Criteria for Social Phobia
Not surprisingly, Janet's social life was extremely limited because of her fears. She had never dated, and only occasionally went to a movie or sports event with a friend from work. Because her social anxiety was quite pervasive, Janet was assigned the diagnosis of social phobia, generalized subtype.
DSM-IV DIAGNOSTIC CRITERIA
In order to make a diagnosis of social phobia according to DSM-IV,2 eight criteria must be met. These are presented in Table 1. In order to qualify for the diagnosis, an individual must demonstrate persistent fear of "one or more social or performance situations," and the primary focus of concern must be related to doing something or displaying anxiety symptoms (e.g., shaking, sweating) that will be humiliating or embarrassing. In children and adolescents, the symptoms must be present for at least 6 months. This ensures that a transient pattern of symptoms exhibited by a child or adolescent does not receive an unwarranted diagnosis.
Upon exposure to the social phobic situation(s), anxiety must be almost invariably elicited. Individuals with social phobia generally experience somatic symptoms of anxiety (e.g., palpitations, sweating) in feared situations, but in some cases, the anxiety response takes the form of a situationally bound or situationally predisposed panic attack. A situationally bound panic attack predictably occurs in anticipation of, or upon exposure to, the phobic situation(s). In the case of a situationally predisposed panic attack, there is an increased likelihood that the feared situation(s) will trigger a panic attack, but the attacks do not invariably occur. DSM-IV also specifies that there must be awareness that the fear is excessive or unreasonable. This criterion is intended to rule out a diagnosis of social phobia in cases in which the concern about interacting or being scrutinized by others is delusional in nature.
There must also be evidence of avoidance of the feared situation(s) or endurance with significant anxiety or distress. It is important to note that either of these conditions is sufficient to satisfy the diagnostic criterion. Furthermore, the social phobic symptoms must produce significant impairment in academic, occupational, or social functioning, or there must be evidence of marked distress about having the disorder. This criterion is intended to rule out "subclinical" cases in which social phobic symptoms are present but not associated with significant distress or impairment in functioning. Because it can be challenging to determine where the boundary should be drawn between clinical and subclinical presentations of social phobia, the clinician must use his or her judgment in assessing whether the degree of impairment or distress exhibited by a patient satisfies the impairment criterion. Guidelines for evaluating functional impairment are presented later in this article.
Two of the DSM-IV diagnostic criteria specify the conditions under which a diagnosis of social phobia is ruled out. The first criterion specifies that the diagnosis should not be made if the symptoms are due to the direct effects of substance use or to a medical condition. Further, the diagnosis is ruled out if the fear is better accounted for by another Axis I or an Axis II disorder. Thus, disorders such as panic disorder with or without agoraphobia, separation anxiety disorder, and body dysmorphic disorder should be considered in formulating a differential diagnosis of the presenting symptoms. Similarly, the second exclusionary criterion rules out a diagnosis of social phobia if the social fears are exclusively related to an Axis III medical condition or another mental disorder. For example, if an individual who stutters presents with significant social anxiety related to a fear of stuttering when speaking to others, then a diagnosis of social phobia is ruled out.
Clinical Characteristics of Social Phobia
DSM-IV also permits designation of the generalized subtype of social phobia if an individual presents with pervasive fear of most social situations. By exclusion, individuals who fear only one situation and those who fear more than one but not most social situations fall outside the boundary of this subtype. Although not explicitly defined by DSMIV, the social phobia literature contains reference to another social phobia subtype that has been described as circumscribed, specific, or discrete.3'4 In practice, this subtype has typically been used to classify individuals who present with fear of one or two specific situations such as public speaking.4
For cases that meet the definition of the generalized subtype, DSM-IV also directs the clinician to consider the additional diagnosis of avoidant personality disorder. Research findings suggest that between 25% and 89% of generalized social phobies also meet the diagnostic criteria for avoidant personality disorder.3,5,6 Individuals with both diagnoses appear to be more severely impaired than generalized social phobies without avoidant personality disorder.3,6
The clinical presentation of social phobia involves several important features. These will be discussed in the following sections. Suggested guidelines for assessing the characteristics in a clinical interview are presented in Table 2.
Social phobic situations can be classified as performance or interactional situations. Performance situations are those in which an individual must engage in behavior that is observed or scrutinized by others, such as making a speech or presentation, eating or writing in front of others, or urinating in a public bathroom. Interactional situations require some degree of interaction with others, such as speaking to strangers, conversing on the telephone, approaching persons in a position of authority, or making eye contact with unfamiliar people. Clinical observations as well as research findings indicate that generalized social phobies tend to present with extensive social anxiety in both performance and social interactional situations. The specific or circumscribed subtype is generally used to designate individuals with only one or two performance-related fears, such as speaking or writing in front of others.
Although not a necessary condition for making the diagnosis, avoidance of anxietyprovoking situations is frequently observed in social phobia. It is not unusual to find that individuals who present with long-standing social phobia have arranged their lives to minimize exposure to feared situations. For example, an individual with severe anxiety about public speaking may repeatedly decline a job promotion that would bring increased demands to make speeches and chair meetings. Some guidelines for assessing phobic avoidance are presented in Table 2.
Individuals with social phobia may experience a broad range of somatic and cognitive symptoms when exposed to feared situations. The somatic symptoms that may occur include palpitations, sweating, trembling, and dry mouth.7 In addition, as mentioned earlier, many social phobies experience panic attacks when exposed to phobic situations.
Among the key distinguishing features of social phobia are the cognitions experienced in the phobic situations. Prototypic cognitions focus on concerns about being embarrassed, humiliated, or negatively evaluated by others (Table 2). Furthermore, research findings have suggested that individuals with social phobia tend to exhibit an excessively self-focused attentional style8 and generate a preponderance of negative thoughts in anxiety-provoking situations.9
Impairment in Functioning
There is relatively little information available concerning the limitations in functioning that occur with social phobia. Findings from the Epidemiologic Catchment Area study10'11 indicated that social phobia is associated with various indices of functional disability, including increased rates of financial dependency (i.e., receipt of disability or welfare payments), suicidal ideation, impaired health status, and difficulties in academic functioning during adolescence.
Recently, Schneier et al12 investigated functional impairment in a clinical sample of social phobies using specialized assessment measures. The findings indicated that more than 50% of the patients experienced at least moderate impairment in functioning at some time during the course of the disorder. Impairment was more likely to occur in the areas of education, employment, family and romantic relationships, friendships, and leisure activities, and less likely to be reported for activities of daily living. In view of recent epidemiologic findings that have elucidated the high prevalence rates of social phobia, additional research efforts investigating the impact of the disorder, particularly in community samples, are clearly needed.
A number of recent papers have reported high rates of comorbidity between social phobia and lifetime diagnosis of panic disorder, with figures ranging from 17% to 50%.n'13-15 Individuals with social phobia also appear to be at significant risk of experiencing major depression at some time in their lives. Based on epidemiologic findings, Schneier et al11 reported a 17% lifetime rate of major depression in individuals with social phobia compared to a rate of 4% in individuals without the disorder. Estimates of comorbidity in clinical samples have been even higher, with figures ranging from 35% to 80%. 15'16 Furthermore, there is evidence that social phobia often temporally precedes the occurrence of major depression, suggesting that the disorder may be a risk factor for the development of depression.11
Elevated rates of alcohol and drug abuse are another significant correlate of social phobia.11 Researchers have suggested that many individuals with social phobia develop difficulties with substance use as a result of attempting to self-medicate their anxiety symptoms,17 although this has recently been questioned.18
Social phobia first entered the diagnostic nomenclature with the publication of the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III).19 As a result, information pertaining to prevalence rates for the disorder did not appear until the mid-1980s when data from the National Institute of Mental Health's Epidemiological Catchment Area (ECA) study became available. In an early report on the ECA findings, Myers et al20 found 6-month prevalence rates for two study sites of 1.2% and 2.2%. More recently, Schneier et al11 examined the prevalence rates for the four ECA sites that assessed for social phobia. They reported an overall lifetime prevalence rate of 2.4%, with figures for the individual sites ranging from 1.9% to 3.2%. In a separate analysis of the data from the Durham ECA site, Davidson et al10 obtained 6-month and lifetime prevalence rates of 2.7% and 3.8%, respectively. Other community studies conducted outside the United States using DSM-III diagnostic criteria reported similar prevalence figures.21
While earlier research reported lifetime prevalence of social phobia of approximately 2% to 3% in the general population, recent studies have found much higher rates. In the largest epidemiologic study to be conducted in the United States since the ECA, Kessler et al22 found a 13.3% lifetime prevalence and a 7.9% 12-month prevalence, making social phobia the third most common disorder after major depression and alcohol dependence. Similarly, Stein et al23 obtained a 7.1% prevalence of current (DSM-III-R) social phobia in a recent telephone survey of social anxiety. The discrepancy between ECA and more recent research findings may be accounted for by instrumentation differences across studies. Specifically, recent studies22'23 have used interviews that assessed a broader range of social situations than the diagnostic interview used in the ECA. In addition, the interview used in the ECA employed a more stringent criterion regarding functional impairment than the DSM criterion, which likely resulted in an underestimation of social phobia prevalence.
It appears that women in the general population are more likely to have social phobia than men. In the ECA study, Schneier et al11 found more than a two- to-one ratio of females to males among those diagnosed with social phobia. Kessler et al22 also reported higher 12-month and lifetime rates of social phobia among women (i.e., 9.1% and 15.5%) than men (i.e., 6.6% and 11.1%).
Age of Onset
Both clinical and epidemiologic studies suggest that social phobia typically begins in early or late adolescence.10'11,15'16 There is also evidence that generalized social phobia develops at a younger age than less pervasive forms of the disorder.3'5 Unfortunately, the research in this area has been hampered by a reliance on retrospective reports obtained, in most cases, at a considerable interval following onset of the disorder. In order to gather more definitive information, longitudinal studies that follow children and adolescents with social phobia into adulthood are needed.
Little empirical data currently exists regarding the long-term course of social phobia in adults. Studies involving clinical and community samples have reported mean durations of illness in the range of 10 to 20 years, implying that the disorder tends to be quite chronic in nature.7'10'24
Recent studies have demonstrated that social phobia is a highly prevalent and often seriously disabling mental health problem. Despite these findings, it appears that a significant number of individuals with social phobia do not receive treatment for the disorder.11 Clearly, an important goal for future research is to systematically investigate the extent of unmet need for treatment among those with social phobia and to identify factors associated with underutilization of mental health services. Other significant challenges for researchers are to further investigate the course of social phobia in both children and adults and to document the longterm impact on functioning.
1. Marks IM, Gelder MG. Different ages of onset in varieties of phobia. Am J Psychiatry. 1966; 123:218-221.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
3. Holt CS, Heimberg RG, Hope DA. Avoidant personality disorder and the generalized subtype of social phobia. J Abnorm Psychol. 1992; 101:318-325.
4. Gelernter CS, Stein MB, Tancer ME, Uhde TW. An examination of syndromal validity and diagnostic subtypes in social phobia and panic disorder. J Clin Psychiatry. 1992; 53:23-27.
5. Schneier FR, Spitzer RL, Gibbon M, Fyer AJ, Liebowitz MR. The relationship of social phobia subtypes and avoidant personality disorder. Compr Psychiatry. 1991; 32:496-502.
6. Turner SM, Beidel DC, Townsley RM. Social phobia: a comparison of specific and generalized subtypes and avoidant personality disorder. J Abnorm Psychol. 1992; 101:326-331.
7. Amies PL, Gelder MG, Shaw PM. Social phobia: a comparative clinical study. Br J Psychiatry. 1983; 142:174179.
8. Hope DA, Gansler DA, Heimberg RG. Attentional focus and causal attributions in social phobia: implications from social psychology. Clinical Psychology Review. 1989; 9:49-60.
9. Bruch MA, Heimberg RG, Hope DA States of mind model and cognitive change in treated social phobies. Cognitive Therapy and Research. 1991; 15:429-441.
10. Davidson JT, Hughes DL, George LK, Blazer DG. The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area study. Psychol Med. 1993; 23:709-718.
11 Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry. 1992; 49:282-288.
12. Schneier FR, Heckelman LR, Garfinkel R, et al. Functional impairment in social phobia. J Clin Psychiatry. 1994; 55:322-331.
13. Sanderson WC, DiNardo PA, Rapee RM, Barlow DH. Syndrome comorbidity in patients diagnosed with a DSM-III-R anxiety disorder. J Abnorm Psychol. 1990; 99:308-312.
14. Stein MB, Shea CA, Uhde TW. Social phobic symptoms in patients with panic disorder: practical and theoretical implications. Am J Psychiatry. 1989; 146:235-238.
15. Van Ameringen M, Mancini C, Styan G, Donison D. Relationship of social phobia with other psychiatric illness. J Affect Disord. 1991; 21:93-99.
16. Stein MB, Tancer ME, Gelernter CS, Vittone BJ, Uhde TW. Major depression in patients with social phobia. Am J Psychiatry. 1990; 147:637-639.
17. Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. Am J Psychiatry. 1990; 147:685-695.
18. Schuckit MA, Hesselbrock V. Alcohol dependence and anxiety disorders: what is the relationship? Am J Psychiatry. 1994; 151:1723-1734.
19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Association; 1980.
20. Myers JK, Weissman MM, Tischler GL. Six month prevalence of psychiatric disorders in three communities. Arch Gen Psychiatry. 1984; 41:959-967.
21. Bland RC, Ora H, Newman SC. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand. 1988; 77:24-32.
22. Kessler RG, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-HI-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994; 51:8-19.
23. Stein MB, Walker JR, Forde DR. Setting diagnostic thresholds for social phobia: considerations from a community survey of social anxiety. Am J Psychiatry. 1994; 151:408-412.
24. Lelliott P, McNamee G, Marks I. Features of agora-, social, and related phobias and validation of the diagnoses. Journal of Anxiety Disorders. 1991; 5:313-322.
DSM-IV Criteria for Social Phobia
Clinical Characteristics of Social Phobia