Social Phobia 341
Rodebaugh (2006) found that GSP with APD was characterized by a more severe form
of social phobia and poorer social skills compared to GSP without APD, with low self-
esteem in the APD group the only qualitative difference. The authors concluded that
DSM-IV APD should be considered a severe form of GSP rather than a separate diag-
nosis.
Beidel and Turner (2007) raise a number of treatment implications that may argue
for the clinical utility of retaining the APD diagnosis. They note that individuals with
APD may have less tolerance for exposure-based treatment and so a more gradual
approach may be necessary. They also indicate that individuals with APD may have
more social skills deficits and lower social/occupational functioning, thereby making
social skills training an essential treatment ingredient when APD is present. Despite
these clinical observations, the empirical research to date suggests that social anxi-
ety should be conceptualized as a continuum of severity with specific or circumscribed
social phobia at the milder end, GSP without APD in the moderate range, and GSP with
APD the most severe form of the disorder (McNeil, 2001).
Clinician Guideline 9.3
Avoidant personality disorder (APD) is a severe form of GSP associated with greater psy-
chopathology and functional impairment. Given the treatment complications that may be
associated with this diagnosis, include an assessment of APD in the diagnostic protocol for
social phobia.epiDemiology anD CliniCal featuresPrevalence
Social phobia is the most common of the anxiety disorders and third most common
over all mental disorders. The NCS employed DSM-III-R criteria for social phobia and
found that 12-month prevalence was 7.9% and lifetime prevalence was 13.3% (Kes-
sler et al., 1994). Moreover, approximately two- thirds of these individuals had GSP,
with the remainder having purely speaking fears that were less persistent and impairing
(Kessler et al., 1998). The more recent NCS-R based on DSM-IV diagnostic criteria
reported a 12-month prevalence of 6.8% and lifetime prevalence of 12.1% for social
phobia (Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). The high prevalence
for social phobia has been found in other epidemiological and large community stud-
ies (e.g., Newman et al., 1996). There is also some evidence that the incidence of social
phobia may be increasing over time (Rapee & Spence, 2004).
As noted previously, milder forms of social anxiety are more prevalent in the general
population than social phobia. Social inhibition, fear of negative evaluation, anxious-
ness, and feelings of inadequacy when in social situations are reported to occur occa-
sionally to moderately often by the majority of nonclinical individuals. Moreover, fear
and avoidance of social situations is common in panic disorder, GAD, and agoraphobia
(Rapee et al., 1988). What distinguishes social phobia is the number of social situations
feared and the degree of functional impairment (Rapee et al., 1988; Stein et al., 2000).