Social Phobias
In recent years social phobia has gained more professional and public interest and increasingly is being recognised as a real anxiety disorder for which treatment can offer an improvement of the patient’s quality of life (Kasper, 1998). Social phobia (social anxiety disorder) usually is rather disabling, characterised by marked fear of performance, excessive fear of scrutiny, and fear of acting in a way that may be embarrassing. Most patients are over-sensitive to the assumed opinion of others and have a low self-esteem, although they feel their fears are exaggerated and out of proportion. Going through the feared situations, or even anticipating them, most people suffer from physical symptoms like sweating, trembling or blushing, and these symptoms can become a trigger on their own to worry about social consequences.
This all can lead to avoidance of many social situations, or they endure these situations with extreme anxiety or distress (Liebowitz, 1999). As in all cases of phobias, the individual recognises that his or her fears are unreasonable.
Social phobia can be divided in two subtypes. The first is generalised social phobia (or complex social phobia), patients being anxious in most situations concerning performance and interactional situations. The patient with non-generalised social anxiety disorder is scared of only one or two (usual performance-related) social situations, such as public speaking, or other public performance, such as writing or eating in front of others (Moutier and Stein, 1999; Stein and Chavira, 1998). Both types, however, tend to be underdiagnosed and undertreated (Stein and Chavira, 1998). There are some differences between the subgroups, the generalised type has even less chance of spontaneous recovery than the non-generalised. In the generalised subtype there is a stronger genetic factor (Kessler et al., 1998b). The generalised subtype is usually more invalidating and carries a higher risk of comorbidity. Age of onset does not differ between the subtypes.
Epidemiology of Anxiety Disorders Introduction
Anxiety disorders have a high impact on daily life (illness intrusiveness) and cause a great deal of suffering for the individual patient (Antony et al., 1998). They also have a substantial impact economically and incur a great deal of expenditure by society as a whole. Greenberg et al. (1999) report a total of $42.3 billion per year as direct and indirect expenses in the USA and there are no obvious reasons to assume that the picture for European countries would be very different (Costa, 1998; Martin, 1998).
In the last decades some large epidemiological studies have provided much information about the occurrence of psychiatric disorders in general and anxiety disorders in particular. The Epidemiologic Catchment Area study (NIMH) and the
Panic Disorder and Agoraphobia
According to DSM-IV (APA, 1994) panic attacks are defined as sudden spells of unidentified feelings consisting of at least four out of 13 symptoms as palpitations, chest strains, sweating, shortness of breath, feelings of choking, trembling, nausea, dizziness, paresthesias, chills or hot flushes, depersonalisation or derealisation, fear of dying or losing control. Although having panic attacks does not imply that the diagnosis of panic disorder can be made and isolated panic attacks are not diagnosed as a disorder, they are often associated with substantial morbidity and do have some clinical significance (Klerman et al., 1991).
In order to make a diagnosis of panic disorder, additional criteria are that these attacks at least once have been unexpected, followed by at least one month of fearful expectation or concern about the consequences of an attack. In the DSM-IV criteria as to the frequency of the attacks (in DSM-III-R, APA 1987, three attacks in a period of three weeks) are abandoned.
Panic disorder is frequently followed (or accompanied) by agoraphobia. Agoraphobia in DSM-IV is defined as (a) fear of being in places or situations from which escape might be difficult or help might not be available; (b) these situations are avoided or endured with marked distress or the patient needs a companion; and (c) the fear is not better explained by another mental disorder.