Social Anxiety Disorder (Social Phobia)

Social anxiety disorder (SAD) is conceptualized as an excessive and/or unreasonable fear of situations in which the person’s behavior or appearance might be scrutinized and evaluated. This fear is a consequence of the person’s expectation to be judged negatively, which might lead to embarrassment or humiliation. Typical examples of feared and usually avoided social situations are giving a talk in public, performing other tasks in front of others, and interacting with people in general. Although the existence of SAD as a psychopathological entity has been known for at least 100 years, it was only relatively recently, with the publication of DSM-III in 1980, that SAD (or social phobia) acquired the status of an ‘‘official’’ psychiatric diagnosis. The term social anxiety disorder has been increasingly used instead of social phobia, because it is felt that the use of the former term conveys more strongly the pervasiveness and impairment associated with the condition and that this term will promote better recognition of the disorder and contribute to better differentiation from specific phobia (Liebowitz et al., 2000). Like generalized anxiety disorder, social anxiety disorder is common and controversial. Unlike generalized anxiety disorder, which is described in different ways by different diagnostic criteria and different researchers and clinicians, SAD does not suffer from a ‘‘description problem.’’ It is not particularly difficult to recognize features of SAD; what may be difficult is making sense of these features. Main issues associated with SAD are listed below…. 1. Where are the boundaries of SAD? How well is SAD distinguished from ‘‘normal’’ social anxiety and shyness on one hand, and from severe psychopathology on the other? 2. Is there a danger of ‘‘pathologizing’’ intense social anxiety by labeling it a psychiatric disorder? How can the distress and suffering of people with high levels of social anxiety be acknowledged if they are not given the corresponding diagnostic label? 3. Is SAD a bona fide mental disorder? 4. Can the subtyping scheme (nongeneralized vs. generalized SAD) be supported? 5. Is there a spectrum of social anxiety disorders?

Anxiety Disorders: Introduction

Anxiety disorders can be defined as conditions characterized by pathological anxiety that has not been caused by physical illness, is not associated with substance use, and is not part of a psychotic illness. Therefore, the concept of anxiety disorders is largely based on exclusion of several causes of pathological anxiety–hardly a scientifically defensible position. Since pathological anxiety has been postulated as the sine qua non of anxiety disorders, it is important to first make a distinction between pathological and ‘‘normal’’ anxiety. For the sake of clarifying this matter, the terms anxiety and fear are used here interchangeably (as they both denote a response to a perceived threat), although there is also a prominent view that conceptual differences do exist between them (see also Table 2—21 and Barlow’s account of panic attacks in Chapter 2 for further discussion of this issue). There is broad agreement that pathological and normal anxiety can be distinguished on the basis of the criteria listed in Table 1—1. These criteria cut across all the components of anxiety: subjective, physiological (somatic), cognitive, and behavioral. Although the criteria may seem clear-cut, in practice it may be difficult to draw a precise boundary between pathological and normal anxiety. It is often assumed that normal anxiety has an adaptive role, because it serves as a signal that there is some danger and that measures need to be taken (e.g., a fight or flight response) to protect oneself against that danger; both the danger perceived and the measures taken are considered appropriate (i.e., not exaggerated) in normal anxiety. For example, a student who is anxious about failing the exam correctly judges herself to be well below the sufficient level of knowledge and doubles the effort to catch up with her studies and minimize the risk of failing. In contrast, pathological anxiety pertains to an inaccurate or excessive appraisal of danger; protective measures taken against this danger are way out of proportion to the real threat. Anxiety disorders were introduced in 1980 as a distinct nosological group in the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980).

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) develops in predisposed individuals who have had a traumatic experience. There are many different ways in which PTSD presents itself, and only some of them(e.g., avoidance behavior, symptoms of hyperarousal)make it look like other anxiety disorders. Various manifestations of PTSD have led to its also being considered primarily a disorder of memory, a dissociative disorder, or a condition more closely related to depression. Given the presumed etiological link between a traumatic event and PTSD, there is a rare opportunity among psychiatric disorders for implementation of strategies that might prevent the development of PTSD. Most people recover after trauma, while many of those who do develop PTSD remit spontaneously. Still, a proportion of traumatized people develop a chronic form of PTSD–a condition that is often very difficult to treat. Posttraumatic stress disorder has been a controversial entity since its official introduction in the psychiatric classification in 1980.Anumber of issues have arisen, and many of them remain unresolved. Some of the key questions are listed below…. 1. Is the concept of PTSD too heterogeneous? 2. Are there different types of PTSD or different disorders arising in the aftermath of trauma? 3. Has the concept of a traumatic event become too broad? Alternatively, can a greater variety of stressful events precipitate PTSD? 4. Is the occurrence of trauma necessary for the development of PTSD? 5. Are there any specific or unique features of PTSD, which would allow its differentiation from related disorders? 6. Has the concept of PTSD been overused or misused, especially in the context of compensation claims and litigation? Does PTSD reflect a ‘‘medicalization’’ of the normal human reactions and emotions in response to trauma? 7. What accounts for the fact that the majority of trauma victims recover spontaneously from early PTSD-like symptoms, whereas some go on to develop a chronic, severe, and debilitating PTSD? Has there been too much emphasis on vulnerability to developing post-trauma psychopathology and too little attention paid to factors such as resilience? 8. Why do we still have a difficulty understanding what combination of risk factors best predicts the development of PTSD?

Obsessive-Compulsive Disorder

As its name implies, the main characteristics of obsessive-compulsive disorder (OCD) are obsessions and/or compulsions. Different types of obsessions and compulsions make OCD a heterogeneous condition. Also, OCD exists on a continuum from mild cases to those with extremely severe and incapacitating manifestations generally not seen in other anxiety disorders. Clinical manifestations of OCD are striking and leave few people who observe them unimpressed. This is arguably due to the seriousness with which persons with OCD take their own obsessions and compulsions along with concurrent realization that these same obsessions and compulsions are senseless and should be gotten rid of. Indeed, there are few other examples in psychopathology where insight and deficiency of insight stand together, and where espousing and fighting the absurd are so intertwined. For all these reasons, OCD is often portrayed as a puzzling or intriguing disorder; in addition, it often represents a treatment challenge. Obsessive-compulsive disorder is probably the least controversial condition within the anxiety disorders because its clinical features are well described and relatively easily recognized and because hardly anyone doubts its existence as a psychopathological entity. What is controversial about OCD, however, is where it belongs and how it should be classified. This is a consequence of a number of features of OCD that make it look different from other anxiety disorders and of the close relationship that OCD has with some conditions outside of the realm of anxiety disorders. Listed below are a number of key questions about OCD…. 1. In view of its different clinical features and the vastly different severity of these features, should OCD be considered a unitary condition or divided into subtypes? 2. If OCD is to be divided into subtypes, on the basis of what criteria should it be done? Types of obsessions and compulsions, reasons for performing compulsions, severity of illness, degree of insight, age of onset, or something else? 3. Should neutralizing responses other than compulsions be given a more prominent role in the description and conceptualization of OCD? 4. How does insight contribute to the conceptualization of OCD? 5. What are the core features of OCD? Is OCD primarily an affective disorder, is it characterized by a primary disturbance in thinking, or is it essentially a disorder of repetitive behaviors?

Specific Phobias

Specific phobias (also referred to as simple phobias and isolated phobias) represent a heterogeneous group of disorders characterized by excessive and/or irrational fear of one of relatively few and usually related objects, situations, places, phenomena, or activities (phobic stimuli). The phobic stimuli are either avoided or endured with intense anxiety or discomfort. People with specific phobias are aware that their fear is unreasonable, but this does not diminish the intensity of the fear. Rather, they are quite distressed about being afraid or feel handicapped by their phobia. Specific phobias are frequently encountered in the general population, but they are relatively uncommon in the clinical setting. Most phobias have a remarkable tendency to persist, prompting an assumption that they cannot be easily extinguished because of their ‘‘purpose’’ to protect against danger. Specific phobias are deceptively simple, as they are easy to describe and recognize but often difficult to understand. There are several conceptual problems and a number of issues associated with specific phobias:… 1. Where are the boundaries of specific phobias? How can we develop better criteria on the basis of which specific phobia could be distinguished as a psychiatric disorder from fears and avoidance considered to be within the realm of ‘‘normality?’’ 2. How can specific phobias be taken seriously by both the sufferers and clinicians? 3. In view of the considerable differences between various types of specific phobias, should they continue to be grouped together? 4. Should specific phobias be grouped on the basis of whether they are driven by fear or disgust? 5. In view of its unique features, should the blood-injection-injury type of specific phobia be given a separate psychopathological, diagnostic, and nosological status? 6. Considering a significant overlap between situational phobias and agoraphobia, should they be grouped together, along a hypothetical situational phobia/agoraphobia spectrum? 7. What is the relationship between specific phobias and other psychopathology? Are they relatively isolated from other disorders, both cross-sectionally and longitudinally, or should they more appropriately be conceptualized as a predisposition to or a risk factor for some psychiatric conditions? 8. How specific are pathways that lead to specific phobias? 9. Has the dominant treatment model for specific phobias, based on exposure therapy, exhausted its potential? Is the tendency for specific phobias to persist adequately addressed by treatments derived from learning theory?

Generalized Anxiety Disorder

The main characteristics of generalized anxiety disorder (GAD) are chronic pathological worry, other manifestations of nonphobic anxiety, and various symptoms of tension. Physical symptoms of anxiety are usually less prominent in GAD than in panic disorder, but they can still be an important component of clinical presentation. Behaviors that are often seen in other anxiety disorders, such as overt avoidance, are conspicuously absent. Unlike all other anxiety disorders, it is more likely for GAD in clinical setting to co-occur with a primary condition for which help has been sought–usually depression or other anxiety disorder–than to be the main reason for seeking professional help. Generalized anxiety disorder is one of the more controversial members of the family of anxiety disorders: it seems that almost every aspect of GAD has provoked debates that do not show signs of abating. Paradox, disagreement, debate, and controversy are the words most commonly associated with GAD. It is small wonder then that the list of ‘‘hot topics’’ related to GAD could be very long indeed. Listed below is a selection of issues thought to represent adequately a more comprehensive list…. 1. What are the characteristic features of GAD that would help in its conceptualization? Pathological worry, other cognitive aspects of anxiety, manifestations of tension, and/or (some) symptoms of autonomic arousal? What combination of these features would ensure that GAD is diagnosed adequately and recognized in clinical practice? 2. What is the relationship between pathological worry and GAD? 3. How can different views on what constitutes the essence of GAD be reconciled? Is GAD a single entity or are there two or more ‘‘types’’ of GAD with distinct clinical characteristics? 4. How is GAD related to depressive disorders, other anxiety disorders, and personality disturbance? Where are its boundaries? In view of its close relationship with depression, should GAD be classified along with depression and perhaps renamed accordingly? 5. Can GAD exist on its own, without depression or other anxiety disorders? What could be features specific enough for GAD that would allow it to establish itself as an independent and valid psychopathological and diagnostic entity? 6. What are the pathophysiological correlates of pathological worry and other aspects of chronic anxiety in GAD? 7. What are the underlying mechanisms and purpose of pathological worry in GAD? What is the meaning of chronic anxiety?

Panic Disorder With and Without Agoraphobia

Panic disorder is characterized by two components: recurrent panic attacks and anticipatory anxiety. Panic attacks within panic disorder are not caused by physical illness or certain substances and they are unexpected, at least initially; later in the course of the disorder, many attacks may be precipitated by certain situations or are more likely to occur in them. Anticipatory anxiety is an intense fear of having another panic attack, which is present between panic attacks. Some patients with panic disorder go on to develop agoraphobia, usually defined as fear and/or avoidance of the situations from which escape might be difficult or embarrassing or in which help might not be available in case of a panic attack; in such cases, patients are diagnosed with panic disorder with agoraphobia. Those who do not develop agoraphobia receive a diagnosis of panic disorder without agoraphobia. Components of panic disorder are presented in Figure 2—1. Patients with agoraphobia who have no history of panic disorder or whose agoraphobia is not related at least to panic attacks or symptoms of panic attacks are relatively rarely encountered in clinical practice. The diagnosis of agoraphobia without history of panic disorder has been a matter of some controversy, especially in view of the differences between American and European psychiatrists (and the DSM and ICD diagnostic and classification systems) in the conceptualization of the relationship between panic disorder and agoraphobia. The conceptualization adhered to here has for the most part been derived from the DSM system, as there is more empirical support for it. Although panic disorder (with and without agoraphobia) is a relatively well-defined psychopathological entity whose treatment is generally rewarding, there are important, unresolved issues. They are listed below and discussed throughout this chapter. …1. Are there different types of panic attacks based on the absence or presence of the context in which they appear (i.e., unexpected vs. situational attacks)? Should the ‘‘subtyping’’ of panic attacks be based on other criteria (e.g., symptom profile)? 2. Because panic attacks are not specific for panic disorder, should they continue to be the main feature of panic disorder? Can panic attacks occurring as part of panic disorder be reliably distinguished from panic attacks occurring as part of other disorders or in the absence of any psychopathology? 3. What is the relationship between panic attacks, panic disorder, and agoraphobia?