Anxiety Disorders 279
most people wouldn’t think twice about being judged, such as eating in the presence
of others or using public restrooms or dressing rooms. People with social phobia
avoid such situations whenever possible—and may even avoid making eye contact
with other people. When a social situation cannot be avoided and must be endured,
the person with social phobia experiences panic or anxiety, sometimes including
symptoms of upset stomach, diarrhea, sweating, muscle tension, and heart palpita-
tions. DSM-IV-TR distinguishes between a social phobia that is limited to specifi c
social performances where the individual is the center of attention—such as making
a presentation—andgeneralized social phobia, which leads a person to fear and
avoid all social situations, as does Rachel in Case 7.4. Table 7.9 lists additional facts
about social phobia.
Table 7.8 • DSM-IV-TR Diagnostic Criteria for Social Phobia
A. A marked and persistent fear of one or more social or performance situations in which the per-
son 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 signifi cantly 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
[discussed in Chapter 14], Body Dysmorphic Disorder [Chapter 8], a Pervasive Developmental
Disorder [Chapter 14], or Schizoid Personality Disorder [Chapter 13] ).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 [Chapter 10].
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision,
Fourth Edition, (Copyright 2000) American Psychiatric Association.CASE 7.4 • FROM THE OUTSIDE: Social Phobia
Rachel was a twenty-six-year-old woman who worked as an assistant manager of a small book-
store. [She sought treatment] for her intense anxiety about her upcoming wedding. Rachel
wasn’t afraid of being married (i.e., the commitment, living with her spouse, etc.); she was
terrifi ed of the wedding itself. The idea of being on display in front of such a large audience
was almost unthinkable. In fact, she had postponed her wedding on two previous occasions
because of her performance fears....
She reported being shy from the time she was very young. When she was in high school,
her anxiety around people had become increasingly intense and had affected her school life.
She was convinced that her classmates would fi nd her dull or boring or that they would notice
her anxiety and assume that she was incompetent. Typically, she avoided doing oral reports
continued on next page