Is Social Phobia a Disorder or Not?

Clinical Psychiatry News - Volume 35, Issue 2, Page 16 (February 2007)

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. I guess the word disorder is better than the word disease for folks who are shy or reticent.

The debates will go on for years about diagnostic labels. Even when it comes to clear disorders such as bipolar spectrum, it's shocking to see the lack of clarity and subjectivity influencing that label. Whether the New Zealanders are right or wrong may not be the question. Ultimately, science, not semantics, will clarify our labeling frenzy in the mental health arena.

My colleagues who use selective serotonin reuptake inhibitors and understand the long-term commitment required with these medications have seen positive results in treating social as well as other types of phobias, as have certain group therapy programs that focus on cognitive restructuring. I continue to prefer the approach I used with the stage fright patients: a combination of relaxation, desensitization, and reciprocal inhibition to alter the individual's reticence about social situations that are sufficiently debilitating that they fit a definition of a phobic response.

In the case of the attorney who failed to show up for job interviews, I explained my learning, philosophizing, and action (LPA) technique so he would understand how, together, we would approach his problem.

He remembered clearly that, while growing up, he was told repeatedly: “You must always look your best and wear nice clothes, because people will judge you on appearances.” His family was not wealthy, and appearances were deemed important. He understood these concepts but found he was unable to control the fear reaction. As I reviewed with him the learned “you'll be judged” concepts of his upbringing, the attorney was able to put them into better perspective by examining ideas of faulty learning influencing his behavior.

From a philosophical point of view, it was clear to see how the patient's family endlessly overemphasized self-awareness and perfectionism, which in the patient took the form of self-consciousness that led to the social hypersensitivity.

The action part of the LPA technique entails teaching the patient a relaxation technique. I like the straight forward eye roll, deep breaths, and encouraging the patient to concentrate on letting his entire body relax. The next step is the use of a large movie screen or great expanse of sky, where the patient sees himself in the stressful/socially phobic situation. In this instance, first using a flashback to the old classroom experiences and then moving into imagining a job interview, I tried to reproduce the stressful experience. All along, I guided the patient through this in vivo desensitization type of imagery.

Clearly seeing the situation but not experiencing it is a beginning in extinguishing this phobic response. Exposure to and flooding of the phobic situation is at work in these behavioral relearning techniques.

As further assistance for the patient, the addition of reciprocal inhibition is integrated into the strategy. Here, we add a dimension to the screen or the sky that the patient is visualizing, in vivo. It's a pleasant set of experiences of his choosing. Suggesting that the patient flip scenes from the phobic experience to the pleasant scene starts him on the road to overcoming the problem as the pleasant scene inhibits the phobic experience. Of course, in vitro desensitization also allows the patient to develop a set of hierarchical situations, such as simulating job interviews with a friend, to actually stimulate the phobic situation. Virtual reality holds great promise for these relearning behavior modification techniques.

Is social phobia a disorder or not? We've seen in psychiatry that names and labels often evolve as trends in DSM development. Let us not forget the DSM-III and the elimination of “neurosis.” When that happened, a generation of fine clinicians lost out to a new nosology, and those confused, maladjusted, neurotic people they were treating who needed a better perspective on their neurotic lives suddenly became “disordered.” Poor Woody Allen. He went from having a great set of neurotic behaviors to having multiple disorders. I would be upset if I were him.

The key point is that we can treat those who have shyness that interferes with daily functioning with numerous approaches—medication, groups, or the relaxation/LPA technique I have developed and used over the years.

Let me know your thoughts on social phobias and I will try to pass them along to my readers.

PII: S0270-6644(07)70071-1

doi:10.1016/S0270-6644(07)70071-1