- 1 DSM-III
- 2 DSM-IV
- 2.1 Diagnostic Criteria
- 2.2 Specifier
- 2.3 Differential Diagnosis
- 2.3.1 Panic Disorder With Agoraphobia
- 2.3.2 Agoraphobia
- 2.3.3 Separation Anxiety Disorder
- 2.3.4 Generalized Anxiety Disorder and Specific Phobia
- 2.3.5 Pervasive Developmental Disorder and Schizoid Personality Disorder
- 2.3.6 Avoidant Personality Disorder
- 2.3.7 Other mental disorders
- 2.3.8 Anxiety Disorder Not Otherwise Specified
- 2.3.9 Performance anxiety, stage fright, and shyness
- 3 DSM-5
- 3.1 Diagnostic Criteria
- 3.2 Specifiers
- 3.3 Differential Diagnosis
- 3.3.1 Normative shyness
- 3.3.2 Agoraphobia
- 3.3.3 Panic disorder
- 3.3.4 Generalized anxiety disorder
- 3.3.5 Separation anxiety disorder
- 3.3.6 Specific phobias
- 3.3.7 Selective mutism
- 3.3.8 Major depressive disorder
- 3.3.9 Body dysmorphic disorder
- 3.3.10 Delusional disorder
- 3.3.11 Autism spectrum disorder
- 3.3.12 Personality disorders
- 3.3.13 Other mental disorders
- 3.3.14 Other medical conditions
- 3.3.15 Oppositional defiant disorder
In DSM-III, this disorder is called Social Phobia
A. A persistent, irrational fear of, and compelling desire to avoid, a situation in which the individual is exposed to possible scrutiny by others and fears that he or she may act in a way that will be humiliating or embarrassing.
B. Significant distress because of the disturbance and recognition by the individual that his or her fear is excessive or unreasonable.
Avoidance of certain social situations that are normally a source of some distress, which is common in many individuals with "normal" fear of public speaking, does not justify a diagnosis of Social Phobia.
Other mental disorders
In Schizophrenia, Major Depression, Obsessive Compulsive Disorder, and Paranoid and Avoidant Personality Disorders, there may be marked anxiety and avoidance of certain social situations. However, the diagnosis of Social Phobia is not made if the phobia is due to any of these disorders.
In Simple Phobia there is also a circumscribed phobic stimulus, but it is not a social situation involving the possibility of humiliation or embarrassment.
In DSM-IV, this disorder is called Social Phobia
A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
- Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)
This specifier can be used when the fears are related to most social situations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority figures, attending parties). Individuals with Social Phobia, Generalized, usually fear both public performance situations and social interactional situations. Because individuals with Social Phobia often do not spontaneously report the full range of their social fears, it is useful for the clinician to review a list of social and performance situations with the individual. Individuals whose clinical manifestations do not meet the definition of Generalized compose a heterogeneous group that includes persons who fear a single performance situation as well as those who fear several, but not most, social situations. Individuals with Social Phobia, Generalized, may be more likely to manifest deficits in social skills and to have severe social and work impairment.
Panic Disorder With Agoraphobia
Individuals with both Panic Attacks and social avoidance sometimes present a potentially difficult diagnostic problem. Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks. Although social situations may be avoided in Panic Disorder due to the fear of being seen while having a Panic Attack, Panic Disorder is characterized by recurrent unexpected Panic Attacks that are not limited to social situations, and the diagnosis of Social Phobia is not made when the only social fear is of being seen while having a Panic Attack. Prototypically, Social Phobia is characterized by the avoidance of social situations in the absence of recurrent unexpected Panic Attacks. When Panic Attacks do occur, they take the form of situationally bound or situationally predisposed Panic Attacks (e.g., a person with fear of embarrassment when speaking in public experiences Panic Attacks cued only by public speaking or other social situations). Some presentations fall between these prototypes and require clinical judgement in the selection of the most appropriate diagnosis. For example, an individual who had not previously had a fear of public speaking has a Panic Attack while giving a talk and begins to dread giving presentations. If this individual subsequently has Panic Attacks only in social performance situations (even if the focus of the fear is on the panic), then a diagnosis of Social Phobia may be appropriate. If, however, the individual continues to experience unexpected Panic Attacks, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. If criteria are met for both Social Phobia and Panic Disorder, both diagnoses may be given. For example, an individual with lifelong fear and avoidance of most social situations (Social Phobia) later develops Panic Attacks in nonsocial situations and a variety of additional avoidance behaviors (Panic Disorder With Agoraphobia).
Avoidance of situations because of a fear of possible humiliation is highly prominent in Social Phobia, but may also at times occur in Panic Disorder With Agoraphobia and Agoraphobia Without History of Panic Disorder. The situations avoided in Social Phobia are limited to those involving possible scrutiny by other people. Fears in Agoraphobia Without History of Panic Disorder typically involve characteristic clusters of situations that may or may not involve scrutiny by others (e.g., being alone outside the home or being home alone; being on a bridge or in an elevator; traveling in a bus, train, automobile, or airplane). The role of a companion also may be useful in distinguishing Social Phobia from Agoraphobia (With and Without Panic Disorder). Typically, individuals with agoraphobic avoidance prefer to be with a trusted companion when in the feared situation, whereas individuals with Social Phobia may have marked anticipatory anxiety, but characteristically do not have Panic Attacks when alone. A person with Social Phobia who fears crowded stores would feel scrutinized with or without a companion and might be less anxious without the added burden of perceived scrutiny by the companion.
Children with Separation Anxiety Disorder may avoid social settings due to concerns about being separated from their caretaker, concerns about being embarrassed by needing to leave prematurely to return home, or concerns about requiring the presence of a parent when it is not developmentally appropriate. A separate diagnosis of Social Phobia is generally not warranted. Children with Separation Anxiety Disorder are usually comfortable in social settings in their own home, whereas those with Social Phobia display signs of discomfort even when feared social situations occur at home.
Although fear of embarrassment or humiliation may be present in Generalized Anxiety Disorder or Specific Phobia (e.g., embarrassment about fainting when having blood drawn), this is not the main focus of the individual's fear or anxiety. Children with Generalized Anxiety Disorder have excessive worries about the quality of their performance, but these occur even when they are not evaluated by others, whereas in Social Phobia the potential evaluation by others is the key to the anxiety.
In a Pervasive Developmental Disorder and Schizoid Personality Disorder, social situations are avoided because of lack of interest in relating to other individuals. In contrast, individuals with Social Phobia have a capacity for and interest in social relationships with familiar people. In particular, for children to qualify for a diagnosis of Social Phobia, they must have at least one age-appropriate social relationship with someone outside the immediate family (e.g., a child who feels uncomfortable in social gatherings with peers and avoids such situations, but who has an active interest in and a relationship with one familiar same-age friend).
Avoidant Personality Disorder shares a number of features with Social Phobia and appears to overlap extensively with Social Phobia, Generalized. For individuals with Social Phobia, Generalized, the additional diagnosis of Avoidant Personality Disorder should be considered.
Other mental disorders
Social anxiety and avoidance of social situations are associated features of many other mental disorders (e.g., Major Depressive Disorder, Dysthymic Disorder, Schizophrenia, Body Dysmorphic Disorder). If the symptoms of social anxiety or avoidance occur only during the course of another mental disorder and are judged to be better accounted for by that disorder, the additional diagnosis of Social Phobia is not made.
Individuals with Social Phobia may be vulnerable to a worsening of social anxiety and avoidance related to a general medical condition or mental disorder with potentially embarrassing symptoms (e.g., tremor in Parkinson's disease, abnormal eating behavior in Anorexia Nervosa, obesity, strabismus, or facial scarring). However, if social anxiety and avoidance are limited to concerns about the general medical condition or mental disorder, by convention the diagnosis of Social Phobia is not made. If the social avoidance is clinically significant, a separate diagnosis of Anxiety Disorder Not Otherwise Specified may be given.
Performance anxiety, stage fright, and shyness
Performance anxiety, stage fright, and shyness in social situations that involve unfamiliar people are common and should not be diagnosed as Social Phobia unless the anxiety or avoidance leads to clinically significant impairment or marked distress. Children commonly exhibit social anxiety, particularly when interacting with unfamiliar adults. A diagnosis of Social Phobia should not be made in children unless the social anxiety is also evident in peer settings and persists for at least 6 months.
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). (Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.)
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety. (Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.)
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
J. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
- Performance only: If the fear is restricted to speaking or performing in public.
Individuals with the performance only type of social anxiety disorder have performance fears that are typically most impairing in their professional lives (e.g., musicians, dancers, performers, athletes) or in roles that require regular public speaking. Performance fears may also manifest in work, school, or academic settings in which regular public presentations are required. Individuals with performance only social anxiety disorder do not fear or avoid nonperformance social situations.
Shyness (i.e., social reticence) is a common personality trait and is not by itself pathological. In some societies, shyness is even evaluated positively. However, when there is a significant adverse impact on social, occupational, and other important areas of functioning, a diagnosis of social anxiety disorder should be considered, and when full diagnostic criteria for social anxiety disorder are met, the disorder should be diagnosed. Only a minority (12%) of self-identified shy individuals in the United States have symptoms that meet the diagnostic criteria for social anxiety disorder.
Individuals with agoraphobia may fear and avoid social situations (e.g., going to a movie) because escape might be difficult or help might not be available in the event of incapacitation or panic-like symptoms, whereas individuals with social anxiety disorder are most fearful of scrutiny by others. Moreover, individuals with social anxiety disorder are likely to be calm when left entirely alone, which is often not the case in agoraphobia.
Individuals with social anxiety disorder may have panic attacks, but the concern is about fear of negative evaluation, whereas in panic disorder the concern is about the panic attacks themselves.
Social worries are common in generalized anxiety disorder, but the focus is more on the nature of ongoing relationships rather than on fear of negative evaluation. Individuals with generalized anxiety disorder, particularly children, may have excessive worries about the quality of their social performance, but these worries also pertain to nonsocial performance and when the individual is not being evaluated by others. In social anxiety disorder, the worries focus on social performance and others' avaluation.
Individuals with separation anxiety disorder may avoid social settings (including school refusal) because of concerns about being separated from attachment figures or, in children, about requiring the presence of a parent when it is not developmentally appropriate. Individuals with separation anxiety disorder are usually comfortable in social settings when their attachment figure is present or when they are at home, whereas those with social anxiety disorder may be uncomfortable when social situations occur at home or in the presence of attachment figures.
Individuals with specific phobias may fear embarrassment or humiliation (e.g., embarrassment about fainting when they have their blood drawn), but they do not generally fear negative evaluation in other social situations.
Individuals with selective mutism may fail to speak because of fear of negative evaluation, but they do not fear negative evaluation in social situations where no speaking is required (e.g., nonverbal play).
Individuals with major depressive disorder may be concerned about being negatively evaluated by others because they feel they are bad or not worthy of being liked. In contrast, individuals with social anxiety disorder are worried about being negatively evaluated because of certain social behaviors or physical symptoms.
Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance that are not observable or appear slight to others; this preoccupation often causes social anxiety and avoidance. If their social fears and avoidance are caused only by their beliefs about their appearance, a separate diagnosis of social anxiety disorder is not warranted.
Individuals with delusional disorder may have nonbizarre delusions and/or hallucinations related to the delusional theme that focus on being rejected by or offending others. Although extent of insight into beliefs about social situations may vary, many individuals with social anxiety disorder have good insight that their beliefs are out of proportion to the actual threat posed by the social situation.
Social anxiety and social communication deficits are hallmarks of autism spectrum disorder. Individuals with social anxiety disorder typically have adequate age-appropriate social relationships and social communication capacity, although they may appear to have impairment in these areas when first interacting with unfamiliar peers or adults.
Given its frequent onset in childhood and its persistence into and through adulthood, social anxiety disorder may resemble a personality disorder. The most apparent overlap is with avoidant personality disorder. Individuals with avoidant personality disorder have a broader avoidance pattern than those with social anxiety disorder. Nonetheless, social anxiety disorder is typically more comorbid with avoidant personality disorder than with other personality disorders, and avoidant personality disorder is more comorbid with social anxiety disorder than with other anxiety disorders.
Other mental disorders
Social fears and discomfort can occur as part of schizophrenia but other evidence for psychotic symptoms is usually present. In individuals with an eating disorder, it is important to determine that fear of negative evaluation about eating disorder symptoms or behaviors (e.g., purging and vomiting) is not the sole source of social anxiety before applying a diagnosis of social anxiety disorder. Similarly, obsessive-compulsive disorder may be associated with social anxiety, but the additional diagnosis of social anxiety disorder is only used when social fears and avoidance are independent of the foci of the obsessions and compulsions.
Other medical conditions
Medical conditions may produce symptoms that may be embarrassing (e.g., trembling in Parkinson's disease). When the fear of negative evaluation due to other medical conditions is excessive, a diagnosis of social anxiety disorder should be considered.
Refusal to speak due to opposition to authority figures should be differentiated from failure to speak due to fear of negative evaluation.