Specific Phobia and Social Anxiety Disorder DSM-5

[Specific Phobia] Diagnostic Criteria

a) marked fear or anxiety about a specific object or situation

b) the object or situation almost always provokes immediate fear or anxiety

c) the object or situation is actively avoided, or is endured with intense fear or anxiety

d) the fear or anxiety is disproportionate to the actual danger posed by the object or situation, and to the sociocultural context

e) the fear, anxiety, or avoidance is persistent, usually lasting 6+ months

f) the fear, anxiety, or avoidance causes significant distress or impairs important areas of functioning

g) the fear, anxiety, or avoidance is not better explained by another disorder

[Specific Phobia] Diagnostic Features

• common for people to have multiple specific phobias: 75% of people with specific phobia have more than one, and the average person with specific phobia has three

  • each phobia gets their own diagnosis reflecting the phobic stimulus

• phobic stimulus categories: animal, natural environment, blood-injection-injury, situational, or other

• the amount of fear or anxiety experienced can vary with proximity to the phobic stimulus or other contextual factors (eg: presence of others, other threatening elements, duration of exposure, etc)

• may cause a full-symptom or limited-symptom panic attack

• active avoidance: person intentionally behaves in a way that’s designed to minimise or prevent exposure to the phobic stimulus

• often people will recognise that their fear is disproportionate, but still overestimate the level of actual danger in the situation that they fear

[Specific Phobia] Prevalence

• 12-month community prevalence in US adults: approx. 8 - 12%

• 3 - 9% in children

• approx. 16% in adolescents

• 3 - 5% in elderly, which may show a decrease in severity of symptoms

• more prevalent in women than men, approx. 2:1

[Specific Phobia] Development and Course

• sometimes develops after a traumatic event, witnessing a traumatic event happen to someone else, having a panic attack in the soon-to-be-phobic situation, or informational transmission (eg: lots of media coverage after a plane crash)

• many people can’t remember why phobia onset occurred

• usually develops in early childhood, with the majority of people having onset before 10 years old 

• situational phobias tend to have later onset age than natural environment, animal, or blood-injection-injury phobias

• average onset age is approx. equal between men and women

• still possible for specific phobias to develop at any age

• specific phobias developed in childhood often wax and wane

• specific phobias that persist into adulthood are less likely to remit

• animal, natural environment, and situational phobias are all predominantly experienced by women; blood-injection-injury phobias are approximately equally experienced by men and women

[Specific Phobia] Etiology

• temperamental

  • negative affectivity (neuroticism) and behavioural inhibition are risk factors for specific phobia and other anxiety disorders

• environmental

  • parental overprotectiveness, parental loss or separation, physical and sexual abuse are all risk factors for specific phobia and other anxiety disorders

  • negative or traumatic encounters with phobic stimulus may trigger the development of specific phobia

• genetic and physiological

  • may be genetic susceptibility to certain categories of specific phobia (eg: first-degree relative with animal phobia means you’re more likely to have animal phobia than another kind of phobia)

  • animal phobia: approx. 32% heritability

  • blood-injury-injection phobia: approx. 33% heritability

  • situational phobia: approx. 25% heritability

[Specific Phobia] Functional Consequences

• associated with suicidal thoughts and suicide attempts

• people with specific phobia show similar levels of impairment in psychosocial functioning and decreased quality of life to people with other anxiety disorders or substance use disorders

• the degree of distress and impairment caused by specific phobia tends to increase with the number of specific phobias someone has

• depending on the phobic object or situation, people may avoid things that exponentially decrease their functionality (eg: fear of falling → reduced mobility, physical functioning, and social functioning; fear of vomiting → reduced food intake; etc)

[Specific Phobia] Differential Diagnosis

• agoraphobia

• social anxiety disorder

• separation anxiety disorder

• panic disorder

• obsessive-compulsive disorder

• trauma and stressor-related disorders

• eating disorders

• schizophrenia spectrum and other psychotic disorders

[Specific Phobia] Differential Diagnosis: Agoraphobia

there can be overlap in the potential feared situation (eg: flying, enclosed spaces, etc); the number of feared situations and the reasons for the fear can help distinguish between agoraphobia and specific phobia.

if there is only a fear of one agoraphobic situation, it’s probably panic disorder; if there’s a fear of two or more agoraphobic situations, agoraphobia may be more appropriate diagnosis.

if the individual’s fear/anxiety is rooted in the idea that they won’t be able to escape or that they won’t be able to get help if they have symptomatic behaviours, agoraphobia; if the situation is feared for another reason (like possible harm to the individual), specific phobia is probably the more appropriate diagnosis.

[Specific Phobia] Differential Diagnosis: Social Anxiety Disorder

if the situation is feared because of what others might think (negative evaluation), that’s social anxiety disorder

[Specific Phobia] Differential Diagnosis: Separation Anxiety Disorder

if the situation is feared because the individual is separated or fears separation from their primary caregiver or attachment figure, that’s separation anxiety disorder

[Specific Phobia] Differential Diagnosis: Panic Disorder

people with specific phobia can have panic attacks, but they are in response to the phobic stimulus; if the panic attacks are random or unexpected (not in response to phobic stimulus), that’s panic disorder

[Specific Phobia] Differential Diagnosis: Obsessive-Compulsive Disorder

if the primary fear or anxiety is because of obsessions and the other criteria for OCD are met, OCD should be diagnosed

[Specific Phobia] Differential Diagnosis: Trauma and Stressor-Related Disorders

if the phobia develops after a traumatic event, PTSD should be considered. specific phobia should only be diagnosed if all the criteria for PTSD aren’t met.

[Specific Phobia] Differential Diagnosis: Eating Disorders

if the avoidance behaviour is exclusively limited to food and food-related cues, specific phobia should not be diagnosed, and anorexia and bulimia should be considered.

[Specific Phobia] Differential Diagnosis: Schizophrenia Spectrum and Other Psychotic Disorders

when fear and avoidance can be attributed to delusional thinking, specific phobia shouldn’t be diagnosed

[Specific Phobia] Comorbidity

• frequently associated with other mental disorders

• early onset age means it’s usually the temporally primary disorder

• people with specific phobia are at higher risk for developing other disorders

• common comorbidities:

  • other anxiety disorders

  • depressive disorders

  • bipolar disorders

  • substance-related disorders

  • somatic symptom and related disorders

  • personality disorders (especially dependent personality disorder)

[Social Anxiety Disorder] Diagnostic Criteria

a) marked fear or anxiety about one or more social situations where the individual may be scrutinised by others (eg: social interactions, performing in front of others, being observed in public)

• in children, this has to happen in peer settings; not just with adults

b) fear that they will act in a way or show anxiety symptoms that will be negatively evaluated

c) the social situation must almost always cause fear or anxiety

d) the social situation is avoided or endured with intense fear or anxiety

e) the fear or anxiety is disproportionate to the threat posed by the social situation and sociocultural context

f) the fear, anxiety, or avoidance is persistent (usually 6+ months)

g) the fear, anxiety, or avoidance causes clinically significant distress or impairment in important areas of functioning

h) the fear, anxiety, or avoidance can’t be attributed to the physiological effects of a substance or another medical condition

i) the fear, anxiety, or avoidance can’t be better explained by the symptoms of another mental disorder

j) if another medical condition is present, the fear / anxiety / avoidance is clearly unrelated or is excessive

[Social Anxiety Disorder] Diagnostic Features

• some people have performance-only social anxiety that impairs their professional lives or their roles that require public speaking. they don’t fear or avoid non-performance social situations.

• fear is rooted in potential judgement from others: that the individual will act in a way (blushing, sweating, stuttering, etc) that will make people think that they’re weird, crazy, stupid, unlikeable, etc.

• may avoid certain activities that could highlight or exacerbate feared behaviours (eg: fear of sweating → avoiding shaking hands and spicy foods)

• the severity and type of fear/anxiety may vary across different occasions (anticipatory anxiety over upcoming class presentation vs panic attack on day of big speech, etc)

• the avoidance of situations may be extensive (skipping school, not going to events) or subtle (limited eye contact, redirecting attention to others, etc)

• important to take sociocultural contexts into account when judging if behaviour is disproportionate

[Social Anxiety Disorder] Prevalence

• 12-month prevalence in US is approx. 7%

• appears to be increasing in US and East Asian countries

• adolescent 12-month prevalence rates are approx. half those of adults

• prevalence decreases after 65

• higher rates in women than men; somewhere between 1.5 - 2.2:1

  • disparity is more pronounced in adolescents and young adults

[Social Anxiety Disorder] Development and Course

• median onset age is 13

• 75% of people have an onset age between 8 and 15, but can develop earlier or later

• onset may follow a stressful or humiliating experience, or develop slowly

• onset in adulthood is relatively rare and is most likely to occur after a stressful / humiliating event or a life change requiring a new social role

• older adults have lower levels of social anxiety disorder across a broader range of situations; younger adults have higher levels of social anxiety disorder for more speciifc situations

• large variation in remission rates, which suggests different trajectories (short, fluctuating, chronic)

[Social Anxiety Disorder] Etiology

• temperamental

  • traits like behavioural inhibition, harm avoidance, fear of negative evaluation, high negative affectivity (neuroticism), and low extraversion are all associated with / may predispose people to social anxiety disorder

• environmental

  • evidence that negative social experiences (esp. peer victimisation) are associated with developing social anxiety disorder

  • childhood maltreatment and adversity are risk factors

  • for Black people in the US, everyday forms of racism and ethnic discrimination are associated with social anxiety

• genetic + physiological

  • traits predisposing people to social anxiety are strongly genetically influenced and are subject to gene-environment interaction (eg: kid with high behavioural inhibition is more susceptible to environmental influences)

  • social anxiety disorder is heritable: 2 - 6x higher chance of development in first-degree relatives

[Social Anxiety Disorder] Functional Consequences

• associated with higher rates of dropping out and decreased levels of well-being, employment, workplace productivity, socioeconomic status, and quality of life

• associated with being single, unmarried, or divorced, and not having children

  • more common in men, while women are more likely to be unemployed

• negatively associated with friendship quality: people with social anxiety disorder report their friendships as less close and less supportive than people without social anxiety disorder

• only around half of people ever seek treatment + tend to only do so after 15 - 20 years of symptoms

[Social Anxiety Disorder] Differential Diagnosis

• normative shyness

• agoraphobia

• panic disorder

• generalised anxiety disorder

• separation anxiety disorder

• specific phobia

• selective mutism

• major depressive disorder

• body dysmorphic disorder

• delusional disorder

• autism spectrum disorder

• personality disorders

• schizophrenia

• eating disorders

• obsessive-compulsive disorder

• other medical conditions

• oppositional defiant disorder

[Social Anxiety Disorder] Differential Diagnosis: Normative Shyness

many people are just shy. only approx. 12% of self-identified shy people in the US have symptoms meeting criteria for social anxiety disorder. diagnosis should only be considered if there’s clinically significant distress or impaired functionality, and should only be made if full diagnostic criteria are met

[Social Anxiety Disorder] Differential Diagnosis: Agoraphobia

both may share a fear and avoidance of social situations, but the agoraphobic fear stems from a lack of escape or help if experiencing symptoms, whereas the social anxiety disorder fear stems from judgement from others. additionally, people with social anxiety disorder are likely calm when left alone; people with agoraphobia often aren’t

[Social Anxiety Disorder] Differential Diagnosis: Panic Disorder

in social anxiety disorder, panic attacks are triggered exclusively by social situations; in panic disorder, panic attacks will happen randomly. additionally, in social anxiety disorder, the distress more likely comes from a fear of negative evaluation from others about the panic attack than the panic attack itself

[Social Anxiety Disorder] Differential Diagnosis: Generalised Anxiety Disorder

in generalised anxiety disorder, social worries are common but tend to focus more on the nature of ongoing relationships. there may be fears around the quality of social performance, but they will also pertain to nonsocial performance and wheno one is evaluating them. social anxiety disorder worries focuse on social performance and others’ judgement

[Social Anxiety Disorder] Differential Diagnosis: Separation Anxiety Disorder

in separation anxiety disorder, avoidance of social settings stems from concern about being separated from attachment figures, and they’re usually fine in social situations where their attachment figures are present. social anxiety will likely still occur in the presence of attachment figures

[Social Anxiety Disorder] Differential Diagnosis: Specific Phobia

people with specific phobia may fear embarrassment or humiliation, but only pertaining to their phobic situations, and usually don’t fear negative evaluation in other social situations

[Social Anxiety Disorder] Differential Diagnosis: Selective Mutism

people with selective mutism may be mute because they fear negative evaluation, but they don’t fear negative evaluation in situations where no speaking is required

[Social Anxiety Disorder] Differential Diagnosis: Major Depressive Disorder

people with major depressive disorder may be concerned about negative evaluation because they feel like they’re bad or unworthy of being liked; people with social anxiety disorder worry about negative evaluation because of social behaviours or physical symptoms

[Social Anxiety Disorder] Differential Diagnosis: Body Dysmorphic Disorder

people with body dysmorphic disorder have social anxiety or are avoidant of social anxiety because of a perceived defect or flaw in their physical appearance that isn’t observable or is barely noticeable to others. if the social fear or avoidance only concerns beliefs about an individual’s appearance, a separate diagnosis of social anxiety disorder isn’t necessary

[Social Anxiety Disorder] Differential Diagnosis: Delusional Disorder

people with delusional disorder might have nonbizarre delusions or hallucinations around delusional themes focusing on being rejected by or offending others. people with social anxiety disorder usually have good insight that their beliefs are disproportionate to the actual threat of a social situation

[Social Anxiety Disorder] Differential Diagnosis: Autism Spectrum Disorder

people with social anxiety disorder typically have age-appropriate social relationships and social communication capacity, though they may seem impaired in those areas when first interacting with unfamiliar people. unless they have comorbid autism, they will likely lack the social communication deficits typical in asd

[Social Anxiety Disorder] Differential Diagnosis: Personality Disorders

social anxiety disorder may resemble personality disorders due to childhood onset and persistence through adulthood — especially avoidant personality disorder. people with avoidant personality disorder have a broader avoidance pattern and higher rates of impairment than people with social anxiety disorder, and have strong and pervasive negative self-concept, sense of not fitting in from early childhood, and view rejection as a global evaluation that they have little worth.

social anxiety disorder is more comorbid with avoidant personality disorder than other PDs and avoidant personality disorder is more comorbid with social anxiety disorder than other anxiety disorders

[Social Anxiety Disorder] Differential Diagnosis: Schizophrenia

social fears and discomfort can appear in schizophrenia, but other evidence for psychotic symptoms should be present for a diagnosis

[Social Anxiety Disorder] Differential Diagnosis: Eating Disorders

it’s important to figure out if the fear of negative evaluation about eating disorder symptoms or behaviours is the only source of social anxiety. if so, that’s not enough to diagnose social anxiety disorder

[Social Anxiety Disorder] Differential Diagnosis: Obsessive-Compulsive Disorder

may be associated with social anxiety disorder, but additional diagnosis should only be made if the social fears / avoidance are independent of the foci of obsessions / compulsions

[Social Anxiety Disorder] Differential Diagnosis: Other Medical Conditions

medical conditions might come with embarrassing symptoms. if the fear of negative evaluation due to medical symptoms is excessive, a diagnosis of social anxiety disorder can be considered

[Social Anxiety Disorder] Differential Diagnosis: Oppositional Defiant Disorder

refusal to speak to oppose an authority figure is not the same as a failure to speak out of fear of negative evaluation

[Social Anxiety Disorder] Comorbidity

• other anxiety disorders — social anxiety disorder usually precedes the onset other than specific phobia and separation anxiety

• major depressive disorder — social anxiety disorder usually precedes the onset, may stem from social anxiety disorder causing chronic isolation

• substance use disorder — social anxiety disorder usually precedes the onset, may stem from self-medicating for social fears, and symptoms may then cause further social fears

• body dysmorphic disorder

• avoidant personality disorder

• in children: high-functioning autism spectrum disorder, selective mutism