340 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Clinician Guideline 9.2
Rather than forming distinct subtypes, social phobia varies along a continuum of severity
with milder forms involving fear of a limited range of social situations and more severe, gen-
eralized social phobia characterized by fear of a wider number of both social interaction and
performance situations.Social Phobia and Avoidant Personality Disorder
A high degree of diagnostic overlap exists between GSP and avoidant personality dis-
order (APD) which has led researchers to question whether they really are two separate
conditions as currently described in DSM-IV (Sanderson, Wetzler, Beck, & Betz, 1994;
Tyrer, Gunderson, Lyons, & Tohen, 1997; van Velzen, Emmelkamp, & Scholing, 2000;
Widiger, 1992). As can be seen from the diagnostic criteria for APD in Table 9.4, both
GSP and APD share much in common because essentially both are characterized by
a pervasive pattern of discomfort, inhibition, and fear of negative evaluation across a
variety of social or interpersonal contexts (Heimberg, 1996).
In his review Heimberg (1996) concluded that approximately 60% of individuals
with GSP will meet criteria for APD compared with 20% of nongeneralized social pho-
bias. Moreover, almost all individuals with APD will meet diagnostic criteria for social
phobia (Brown, Heimberg, & Juster, 1995; Herbert et al., 1992; Turner et al., 1992).
Given this close relationship between GSP and APD, an assessment for APD should be
made whenever individuals meet diagnostic criteria for social phobia.
Comparison of the clinical presentation between GSP with and without APD have
generally revealed that those with GSP and APD have greater symptom severity, diag-
nostic comobidity, functional impairment, social skills deficiencies, and possibly less
motivation and response to CBT (e.g., Holt et al., 1992; van Velzen et al., 2000; see
also Beidel & Turner, 2007; Heimberg, 1996). More recently Chambless, Fydrich, and
table 9.4. Dsm-iv-tr Diagnostic Criteria for avoidant personality Disorder
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative
evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four
(or more) of the following:
(1) avoids occupational activities that involve significant interpersonal contact, because of fears of
criticism, disapproval, or rejection
(2) is unwilling to get involved with people unless certain of being liked
(3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed
(4) is preoccupied with being criticized or rejected in social situations
(5) is inhibited in new interpersonal situations because of feelings of inadequacy
(6) views self as socially inept, personally unappealing, or inferior to others
(7) is unusually reluctant to take personal risks or to engage in any new activities because they may
prove embarrassing
Note. From American Psychiatric Association (2000). Copyright 2000 by the American Psychiatric Association.
Reprinted by permission.