Social Anxiety Disorder

(Social Phobia)

Differential Diagnosis

The diagnosis of Social Anxiety Disorder (a.k.a. Social Phobia), takes place when there are recurrent attacks of anxiety; isolated crises are not enough. If the person is under the age of eighteen, the crises must occur for at least six months.

For the inexperienced professional, the diagnosis may be misleading. Let us see the chief mistakes in the differential diagnosis and why they happen.

The main mistakes have to do with:
*Schizophrenia
*Panic Disorder
*Depression
*Shyness

Let us look at each one.

Differential Diagnosis with Schizophrenia – When the client claims that he is observed in the street and "sees" people criticizing him, the professional may think about hallucinations or ideas of reference and label the client as schizophrenic. The client's conviction must be checked out to see, if needed, further investigation is in order.

In Social Anxiety Disorder / Social Phobia, the person in crisis is convinced of being observed, judged, and belittled. Outside the crisis, the person acknowledges that her thoughts were irrational. Attention: When seeking help, the person with years of generalized anxiety attacks in social situation may take some time to recognize that her thoughts are irrational. The conviction is maintained in schizophrenia.

Moreover, the social phobic person has no anxiety crises nor any such hang-ups with close relatives, while the schizophrenic with hallucinations and persecution or referential ideas commonly extends the distortion of reality to the family.

Differential Diagnosis with Panic Disorder - When Social Anxiety Disorder / Social Phobia attacks take on major proportions, panic becomes quite similar to Panic Disorder. The fundamental difference may be found in the clinical history.

Four aspects must be carefully observed regarding the mistakes with Panic Disorder:

1. Predictability of the Crises – In Panic Disorder, the panic attacks are unpredictable, with no association with any type of exposition. In Social Phobia, panic only occurs when there is exposition (in some cases in the expectation of the exposition too).

2. Feelings Well Defined – In the attack of Panic Disorder the person has the feeling that he is going to faint or go crazy or die from a heart attack. In panic from Social Anxiety this does not occur, but the person has an urgent need to go away from the situation.

3. Differences in Evolution of the Panic Attacks – In Panic Disorder, it's common for the person to go on feeling bad for a long time (several hours or one day) after the attack. In Social Anxiety Disorder it's common for the person to recover quickly his habitual emotional condition after the attack, once out the situation.

4. Social Phobia Added to Panic Disorder - The person begins with typical Panic Disorder crises (which technically, in behaviorism, can be called an unconditioned, unidentified eliciator) and associates them with places or situations he is in. These places or situations trigger high anxiety. The person then avoids them because they "signal" the possibility of anxiety attack. (Technically, in behaviorism, any of these situations or places is an identifiable conditioned eliciator.)

The crises are repeated in other circumstances (the number of eliciators increases) and the person continues the process of closing her life space. The fear of crises generates intense anxiety, similar to the initial Panic Disorder crisis, if the person is exposed to the same places or situations. This "confirms" her impression that the attacks are triggered by the exposition. The situation is usually complex and requires painstaking investigation in the diagnosis of overlapping.

Differential Diagnosis with Depression – Another mistake involves the person's humor or mood. Given the suffering described, the person comes to the professional with low humor. The diagnosis of Depression is made. This diagnosis is not wholly wrong: the mood is indeed depressed. But it is a case of Reactive Depression. The core of the suffering is in a different sphere, in the consequences of the phobia, in the limitations imposed on the person's life. This depressive state is usually reinforced by the reactivation of memories: difficulties lived through, situations in which the person felt ashamed, missed opportunities, etc.

Differential Diagnosis with Shyness – It is common to see descriptions of serious Shyness that actually fit perfectly into the description of Social Anxiety / Social Phobia. In other cases, the distinction is more difficult, for there seems to be a continuous gradation from the mildest Shyness to clear-cut instances of social phobia. Sometimes the borderline between the two is so fine that the diagnosis impression oscillates from one to other.

To be faithful to the empirical observations, I should not introduce this item as one of the possible mistakes in diagnosis. I deem it perfectly possible that Social Phobia may be a more serious case of Shyness. However, to make understanding and communication easier, a reference is necessary, especially for such cases in which the person's activities are harmed.

The World Health Organization has developed references for all the diseases with the International Disease Classification. This reference has been changing over the years. Groups of experts worldwide have been contributing to improve it. It is possible that this evolution will consider Social Anxiety Disorder / Social Phobia not as a nosological entity, as now, but as a worsening form of Shyness.

The Mistake Becomes Truth – In two of the situations described, the mistake can be perpetuated by the simple fact that the bearer of Social Phobia responds well to certain medications, especially antidepressants. I refer to depressed persons (including reactive depression) and persons with Panic Disorder. Medication to treat depression or Panic Disorder in fact can improve the Social Phobia. Improvement is regarded as confirmation that the person had depression or Panic Disorder.

If the mistake relates to schizophrenia, the specific anti-psychotic medication does not bring about any improvement.

In any case, mistakes in medical or psychological diagnosis are common.

Read other article on this subject at Panic Disorder, Shyness, Social Anxiety/Phobia

September, 2004.
Updated January, 2006

E-mail this page

Please read the Disclaimer-Purpose before e-mail or print this page.