Magazine article Clinical Psychiatry News

Is Social Phobia a Disorder or Not?

Magazine article Clinical Psychiatry News

Is Social Phobia a Disorder or Not?

Article excerpt

A bright young attorney was referred to me a few years ago by his primary care physician. The attorney had passed the bar exam and had had no problems securing and scheduling job interviews, but for more than 6 months after passing the bar, he had canceled, rescheduled, or even failed to show up for those interviews.

In our first meeting, I ruled out many DSM possibilities. However, after talking with him I noticed a theme: In college and law school, he often showed up for classes infrequently at the beginning of the semester because of first-day anxiety and stress, which took the form of fear. He knew that his fear was well out of proportion to the situation. Nevertheless, he seemed unable to control it.

A year ago, I did a column on stage fright, and several readers wrote in asking about comparisons with social phobias as defined in the DSM ("Treating Stage Fright," February 2006, p. 27).

Certainly, similarities exist between stage fright and social phobias. Often, we find that those with stage fright do fit the DSM diagnosis of social phobia. My previous column focused on people involved in some form of performance who were highly motivated to resolve their problems because of career and financial considerations. My intent here, however, is to focus on social phobias that have less potential to affect a person's entire career, although one could certainly argue that the attorney's self-sabotage could have had far-reaching implications for his.

Many social phobia patients have anxieties that center on giving a speech in public, such as at a PTA meeting or simply speaking up in a public place like in a store or a post office.

Culturally, certain groups of people tend to be shy and self-effacing, and were it not for the influence of the DSM they might be considered shy rather than pathologic. I've spoken with several New Zealanders, for example, who find Americans quite expressive and demonstrative, and have suggested that shyness may be interpreted as a social phobia in the United States, especially when people worry too much about so many things, including speaking in public.

Those considered reserved or shy behavior in other cultures may be just that, and a medical diagnosis may not be appropriate. It's not only some New Zealanders I know who have questioned the validity of characterizing social phobia as a disorder. Many thoughtful clinicians wonder whether we are overusing diagnostic labels to the point that they lose some credibility. A psychiatric social worker I know, Rosemarie Carloni, suggests that many people who are shy and socially apprehensive do not meet the standard of social phobia. Yet, too often, they are diagnosed this way and are led into a medicinal model of treatment for a personality style that should be worked out conceptually, said Ms. Carloni, who has more than 20 years' clinical experience.

It's difficult to offer a diagnostic label for people who are shy, though some patients experience shyness that proves debilitating. Despite DSM criteria for this disorder, the subjectivity that enters into diagnostic labeling in these situations, as well as many others, leaves a void yet to be filled. I suspect that not until we have genuine biologic or radiographic markers will nosology lose much of its subjective character.

However, if a person's level of function is impaired to the point that he is unable to perform tasks because of an overwhelming physiological/psychological response--he needs to show up for a job interview but suffers a severe enough reaction to the idea of an appearance or performance that physiologic changes occur and anxiety and panic set in--I guess we can call it a disorder.

This is different from a person who wants to control a proclivity to blush and spends months with a psychotherapist who tries to understand this person's social phobia using her own definition of DSM social phobia, that is, blushing. …

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