The patient is a 10-year-old boy who was brought to the clinic by his mother, who believes he is suffering from social phobia. The mother’s concern for her son stems from his poor eye contact, his preference to play alone, and his lack of peer friendships. According to the mother, her son spends most of his free time by himself on the computer, usually searching the Internet for superhero-related information. She interprets this behavior as his way of decompressing once he is away from the anxiety of being surrounded by people all day at school.
The mother reported that the boy has a particularly difficult time in school during lunch period because he is required to go to the cafeteria where he encounters unfamiliar students from other classes. He tries to avoid going to the cafeteria by frequently asking his teacher if he can eat in the classroom or go to the school nurse instead. In addition, the patient reportedly becomes extremely upset and has long, uncharacteristic tantrums when he is required to visit family friends or when his parents have visitors come to the house.
Medical and Psychiatric History
According to the patient’s mother, the patient is the product of a normal 40-week pregnancy delivered vaginally with unremarkable pre-, peri-, and postnatal history. Developmental motor milestones were reached at expected time frames (sitting at 6 months and walking at 13 months). However, he had a delay in speaking single words (2.5 years) and in using communicative phrases (3.5 years). Family history is significant for bipolar disorder, schizophrenia, and depression. In terms of the patient’s educational history, he has attended mainstream public schools throughout his academic career.
Upon detailed questioning by the examiner regarding the patient’s social difficulties, his mother described that he seems unsure how to initiate and sustain interaction with others, and he displays inconsistent responses to social initiations from peers. According his mother, the patient never had an appropriate peer friendship and has always preferred to play by himself. She recalled that as a toddler, he rarely engaged in imaginative play or played with others, but would rather play repetitively with the same toy by himself for hours. The patient’s mother also described difficulties in pragmatic language as a young child as well as currently, including difficulty reading nonverbal communication and cues, and difficulty staying on topic and with reciprocal conversation.
When asked about details regarding the quality of conversations with the patient, his mother explained that he likes to tell people facts about superheroes. She described that speaking with her son is typically one-sided; he is unaware when others are not interested in his knowledge of superheroes, and it is hard to transition him to other topics of conversation.
When asked if the boy has ever had any other intense interests, his mother revealed that he has had many circumscribed interests that have changed over time. For example when he was younger, Thomas the Tank Engine was virtually the only subject he would talk about, he would need to have a Thomas train with him at all times, and would only eat off of a Thomas plate.
The patient presented as a cheerful young boy. His functioning language skills were age appropriate, and he was able to use comprehensive spontaneous language to provide answers to direct questions. For example, when asked by the examiner if he becomes nervous or afraid when he is with classmates, he responded, “No, I always tell David about superheroes, nobody else likes superheroes; well, only Michael but he likes DC superheroes not Marvel.” In response to being asked if he becomes scared when he is with people he does not know, he responded, “No, I like to meet new people.” When asked why he does not like when visitors come to the house, he responded “It is really annoying because then mom doesn’t let me use the computer”; when asked why he does not like to go to the school cafeteria for lunch, he responded, “It is very loud in the cafeteria, people are running and jumping around, and it smells disgusting.” Upon further questioning regarding possible sensory sensitivities, the patient acknowledged that loud sounds or “chaos” often hurt his ears, and that he dislikes and becomes “upset” by some smells, including pizza, hamburgers, and perfume.
Throughout the interview, it was difficult for the patient to engage in conversations outside of his topic of interest of superheroes. With regards to nonverbal communication, he spontaneously used various types of communicative gestures; however, appropriate eye contact was limited, as was his range of facial expressions to regulate social interactions. The patient appeared at times to be socially engaged but several of his social overtures were odd or inappropriate.
High-Functioning Autism Spectrum Disorder
The patient’s mother suspected that the patient was suffering from social phobia due to the fact that he prefers to play alone, does not have appropriate peer friendships, and has poor eye contact. In addition, she noted that her son avoids activities in which he is required to be in the presence of other people (eg, lunch in the school cafeteria and visitors at home).
According to DSM-IV-TR1 criteria, to be diagnosed with social phobia one must have a marked and persistent fear of one or more social or performance situations in which the individual is exposed to unfamiliar people or to scrutiny by others. In addition, exposure to the feared social situation provokes anxiety, which in children may be expressed by crying, tantrums, or avoiding social situations.
The fact that the patient denied any fear or anxiety related to social situations precludes a diagnosis of social phobia. Further, although he does throw tantrums to avoid specific social situations, such as going to the school cafeteria or having visitors over the house, his avoidance is not due to fear of a social situation or to being scrutinized by others. Rather, his avoidance of these situations results from sensory sensitivities and to the dread of being prohibited from partaking in an enjoyed activity, respectively.
Alternatively, the history and behavior pattern described by the patient’s mother and observed by the examiner are suggestive of a diagnosis of high-functioning autism spectrum disorder (ASD). More specifically, the patient demonstrated a qualitative impairment in social interactions (eg, impairment in the use of multiple nonverbal behaviors, failure to develop peer relationships appropriate to developmental level), qualitative impairments in communication (impairment in the ability to initiate and sustain a conversation), and restricted repetitive and stereotyped patterns of behaviors, interests, and activities (currently superheroes), with onset before age 3 years. Of note, heightened sensory sensitivies, such as those experienced by the patient, are commonly associated with ASD.
Both social phobia and high-functioning ASD are marked by impairments in social interactions, poor eye contact, and difficulty forming friendships. As such, on the surface they may appear to have a similar behavior profile. However, whereas the social difficulties in social phobia are marked by an underlying fear and avoidance of social situations, in ASD there is no primary anxiety related to social deficits. Similarly, core features in ASD, including restricted and repetitive behaviors and language delays or deficits, are not diagnostic for social phobia. Further, to meet criteria for ASD, the abnormal functioning has to occur with onset before age 3 years.
In contrast, social phobia typically starts in early adolescence to young adulthood.2 Thus, besides the difference in origin of symptoms (ie, anxiety in social phobia) and the symptoms themselves, there is a differential developmental trajectory to the two disorders.
Interestingly, as individuals with high-functioning ASD reach adolescence and social demands increase, so may a more acute awareness of one’s social deficits and its consequences. This awareness and ability for self-reflection may trigger a fear and avoidance of social situations that is significant enough to warrant a diagnosis of social phobia.3–5 In fact, prevalence estimates for social phobia in ASD range from 7% to 29.2%.6,7
When considering a differential diagnosis, it is important to consider to what to attribute the anxiety. If the cause of the anxiety lies in the social realm (eg, fear of being embarrassed or of being negatively evaluated), one may contemplate a diagnosis of social phobia. However, if the anxiety were a consequence of more nonsocial circumstances (eg, predictable sensory reactions or a change in routine), then ASD without comorbid social phobia would be the appropriate diagnosis.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). Washington, DC: American Psychiatric Publishing; 2000.
- Alfano CA, Beidel DC, Turner SM. Cognitive correlates of social phobia among children and adolescents. J Abnorm Child Psychol. 2006;34:189–201. doi:10.1007/s10802-005-9012-9 [CrossRef]
- Attwood T. The Complete Guide to Asperger’s Syndrome. London and Philadelphia: Jessica Kingsley Publishers; 2007.
- Meyer JA, Mundy PC, Van Hecke A, Durocher JS. Social attribution processes and comorbid psychiatric symptoms in children with Asperger’s syndrome. Autism. 2006;10:383–402. doi:10.1177/1362361306064435 [CrossRef]
- Wing L. Asperger’s syndrome: a clinical account. Psychol Med. 1981;11:115–129. doi:10.1017/S0033291700053332 [CrossRef]
- Leyfer OT, Folstein SE, Bacalman S, et al. Cormorbid psychiatric disorders in children with autism: interview development and rates of disorders. J Autism Dev Disord. 2006;36:849–861. doi:10.1007/s10803-006-0123-0 [CrossRef]
- Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G: Psychiatric disorders in children with autism spectrum disorders: prevalence, co-morbidity, and associated factors in a population-derived sample. J Am Acad Child Adolesc Psychiatry. 2008;47:921–929. doi:10.1097/CHI.0b013e318179964f [CrossRef]