Subtypes of social phobia and comorbidity with depression and other anxiety disorders

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Abstract

Epidemiological studies have identified two subtypes of social phobia: speaking-only social phobia which is characterized by the fear of public speaking situations and complex social phobia which is characterized by the fear of multiple social situations. Speaking-only social phobia most closely corresponds to the DSM-IV's `nongeneralized social phobia' while complex social phobia resembles `generalized social phobia'. In contrast to the speaking-only social phobia, the complex form is usually more disabling, familial and longer-lasting. In addition, the complex form has a lower chance of spontaneous recovery and carries a higher risk of comorbidity and impairment. Overall, both types of social phobia tend to be underdiagnosed and under-treated. Effective treatments which can manage not only complex social phobia, but also its spectrum of comorbid conditions, are required.

Introduction

Social phobia is a relatively recently recognized psychiatric disorder, first receiving increased attention during the 1980's (Liebowitz et al., 1985). It is characterized by a fear of situations where the individual may be exposed to the scrutiny of others. The most commonly feared situations are performance situations, such as public speaking and eating or writing in front of others; however, some sufferers fear any form of social interaction, including attending a party or speaking to a teacher or employer.

The hallmark of this disorder is a fear of negative evaluation. Specifically, the person fears that he or she will say or do something humiliating or that they may show signs of anxiety in front of others. As a result, social situations are either avoided, or endured with distress. In its severe forms, social phobia may therefore become a disabling disorder, limiting achievement in education or employment and eroding self-esteem and confidence (Butler and Wells, 1995, Schneier et al., 1992, den Boer, 1997). Patients may also become socially isolated, depressed and demoralized, and some may turn to alcohol in an attempt to self-medicate (Davidson et al., 1993, Schneier et al., 1992).

As social phobia has only recently been recognized even by mental health specialists, and given that consulting a physician is itself a social situation likely to be feared and avoided, many patients with social phobia experience their illness in silence (Butler and Wells, 1995, Stein, 1996). As a result, the disorder tends to be under-diagnosed and under-treated.

Only with recent large-scale epidemiologic studies of psychiatric disorders has the true prevalence of social phobia been recognized. The National Comorbidity Survey, conducted on a large population sample in the USA, reported a lifetime prevalence of social phobia of 13.3% and a 12-month prevalence of 7.8% (Kessler et al., 1994, Magee et al., 1996). A Canadian study, the Mental Health Supplement of the Ontario Health Survey, used identical methods and found similar, although slightly lower rates (Offord et al., 1996). In that study, social phobia was the most common psychiatric disorder, with a one-year prevalence of 5.4% in men and 7.9% in women. Other large studies have also consistently found that social phobia exhibits a high degree of comorbidity with other psychiatric disorders such as other phobias, depression, panic disorder, and substance abuse (Davidson et al., 1993, Magee et al., 1996, Schneier et al., 1992). In addition, social phobia has been associated with a higher incidence of suicidal ideation (Schneier et al., 1992) and suicide attempts (Davidson et al., 1993), particularly in patients with other comorbid disorders (Schneier et al., 1992).

With increased research, it is also becoming apparent that social phobia is not a single entity, but rather consists of at least two distinct subtypes which differ in clinical characteristics, heritability, patterns of comorbidity, and in degree of associated social impairment (Heimberg et al., 1990, Levin et al., 1993, Mannuzza et al., 1995, Kessler et al., 1998). This paper describes two subtypes and the evidence supporting the distinction between them. It also briefly discusses the potential implications for the diagnosis and treatment of social phobia.

Section snippets

Subtypes of social phobia

Practising psychiatrists have recognized two subtypes of social phobia in the clinical setting. The first type, sometimes called `discrete', `specific' or `nongeneralized' social phobia, is the more familiar of the two. It is usually confined to a fear of one or a few situations, of which the most common is speaking in front of an audience (Schneier et al., 1992, Stein et al., 1996). Usually nongeneralized social phobia is not disabling although it may lead to under-achievement at work or

Familial associations in social phobia subtypes

Findings from family studies (Mannuzza et al., 1995, Chapman et al., 1995, Fyer et al., 1993, Reich and Yates, 1988) and twin studies (Kendler et al., 1992) suggest that there is a heritable component to social phobia. Few studies however, have investigated this relationship in social phobia subtypes. In one study, Stein et al. (1998)investigated this question by conducting structured clinical interviews on as many as possible of the first-degree relatives of patients with generalized social

Comorbidity in social phobia subtypes

As previously noted, social phobia exhibits a high degree of comorbidity with other psychiatric disorders. This finding has been consistently replicated in numerous research studies (Table 3); however, in these studies social phobia subtypes were usually not delineated.

Recent findings from the NCS (Kessler et al., 1998) have reported that the prevalence of comorbid conditions is higher in patients with complex (generalized) social phobia than in patients with speaking-only social phobia, as

Conclusion

It remains to be determined to what extent the epidemiologically derived `complex' type of social phobia corresponds to the clinically-derived `generalized' type. It seems likely that the former category encompasses the latter, but also includes some persons whose social phobia is somewhat less than generalized. More importantly however, complex (generalized) and speaking-only (discrete or nongeneralized) social phobia seem to be distinct syndromes, distinguishable in their symptoms, natural

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