Social Phobia 345
social phobia have high rates of comorbid alcohol use disorders that may be linked to
fears of negative evaluation and expectancies that alcohol will reduce social anxiety.
Given the significant decline in function associated with social phobia, a large num-
ber of individuals with social phobia also develop major depression as well as elevated
rates of suicidal ideation and attempts (Schneier et al., 1992). In fact both simple (24.3%)
and social phobia (27.1%) had the highest lifetime rates of secondary major depres-
sion within the anxiety disorders in the NCS, with the occurrence of major depression
approximately 11.9 years after the onset of social phobia (Kessler et al., 1996). Finally,
Axis II disorders are commonly associated with social phobia, the most frequent being
APD, although elevated rates of dependent and obsessive– compulsive personality dis-
orders have also been reported (see Beidel & Turner, 2007; Heimberg & Becker, 2002;
Turner, Beidel, Borden, Stanley, & Jacobs, 1991).
According to DSM-IV-TR, a diagnosis of social phobia is not made when the social
anxiety and avoidance concern the potential embarrassment arising from a general
medical condition such as tremors due to Parkinson’s disease, facial scarring, obesity,
stuttering, or the like (APA, 2000). However, this prohibition may be too stringent.
Stein, Baird, and Walker (1996), for example, found that 44% of patients seeking treat-
ment for stuttering met diagnostic criteria for social phobia when the diagnosis was
made only when the social anxiety was in excess to the severity of their dysfluency. Thus
a careful assessment of the context and severity of the social anxiety is needed to deter-
mine if it is a reasonable or exaggerated response to the general medical condition.
Clinician Guideline 9.5
Given the high rate of comorbid major depression, generalized anxiety, specific phobias, ago-
raphobia, and substance abuse in social phobia, the clinician must include a thorough diag-
nostic assessment for these conditions when treating social phobia. In addition frequency,
intensity, and duration of panic attacks and suicidal ideation should be assessed prior to
treatment.Negative Life Events and Social Adversity
Like other anxiety disorders, social phobia is associated with an increased rate of child-
hood adversities, though the relationship is not as strong as seen in the mood disorders
(Kessler, Davis, & Kendler, 1997). In their etiological model of social phobia, Rapee
and Spence (2004) proposed that negative life events and more specific learning expe-
riences can contribute to increased risk of pathological social anxiety for individuals
with a genetically mediated high social anxiety “set point.” In the present context we
are more interested in whether certain adverse interpersonal events in childhood or
adolescence might play an etiological role in social phobia or whether individuals with
social phobia experience more adverse, even traumatic, interpersonal events that could
reinforce their social anxiety.
Heritability estimates suggest that 30% of the disease liability in social phobia is
due to genetic factors, leaving considerable room for the influence of environmental
factors (Kendler et al., 1992b). In fact a significant association has been found between
traumatic events in childhood such as physical or sexual abuse as well as childhood