____________________________________________________________________________ Anxiety Disorders
Major personality dimensions, such as introversion and neu- roticism, have been studied for contribution to the risk of developing agoraphobia and other anxiety disorders. Genetic factors that influence individual variation in extraversion and neuroticism have been found to account entirely for genetic liability in SAD and agoraphobia but not animal phobia, emphasizing the importance of both introversion (low extraver- sion) and neuroticism as risk factors [115]. Situational avoid- ance is the most disabling aspect of agoraphobia. Temperament is shown to influence agoraphobia severity, with introverted temperament significantly associated with the presence and severity of agoraphobic situational avoidance [9]. The longitudinal relationship between personality disorder traits and panic disorder (with or without agoraphobia) is important for understanding agoraphobia etiology. A large- scale study that assessed community-dwelling adults at base- line and again 12 to 15 years later found that after excluding participants with baseline panic attacks, baseline timidity with avoidant, dependent, and related traits predicted the onset of panic disorder or panic disorder with agoraphobia during the follow-up period. These results suggest that avoid- ant and dependent personality traits are predisposing factors, or markers of risk, for panic disorder or panic disorder with agoraphobia, and not simply epiphenomena [24]. Additionally, personality and temperament traits may be potentially related to poor treatment response [116]. SOCIAL ANXIETY DISORDER SAD is often misconstrued as mere shyness but can be consid- erably disabling and produce much greater distress and more severe symptoms. SAD is characterized by a marked, persistent, and unreasonable fear of being observed or evaluated negatively by other people in social or performance situations, which is associated with physical and psychologic anxiety symptoms. Feared situations, such as speaking to unfamiliar people or eating in public, are either avoided or are endured with significant distress [3]. Social phobia has been renamed SAD to reflect a new, broader understanding of the condition in a variety of social situations. Previously, social phobia was primarily diagnosed in patients reporting extreme discomfort or fear when performing in front of others. Research indicates this definition is too narrow, and SAD in the DSM-5 can be diagnosed based on patient response to a variety of social situations. For example, the patient may be so uncomfortable engaging in conversation he or she is unable to talk to others, especially strangers. A patient with anxiety regarding being observed may be unable to go out to dinner over fears of being watched while eating and drinking [102]. The defining features of SAD diagnosis remain unchanged. However, some modifications in require features have been made, including deletion of the requirement that individuals older than 18 years of age must recognize their fear or anxiety is excessive or unreasonable, and addition of a duration criterion. A more significant change is that the “generalized” specifier has
been deleted and replaced with a “performance only” specifier. The DSM-IV-TR generalized specifier was problematic in that “fears include most social situations” was difficult to opera- tionalize. Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of SAD in terms of etiology, age at onset, physiologic response, and treatment response. The DSM-5 establishes the following diagnostic criteria for SAD [2]: • Marked fear or anxiety about social situations in which the person may be exposed to scrutiny by others • Fear that actions or showing anxiety symptoms will cause negative evaluation (e.g., embarrassment, humiliation) or offend others • The social situation: ‒ Almost always provokes fear or anxiety ‒ Is actively avoided or endured with marked fear or anxiety • The fear, anxiety, or avoidance: ‒ Is disproportionate to actual threat posed by the social situation ‒ Is persistent, typically at least six months ‒ Causes significant distress or functional impairment • If another medical condition is present (e.g., stuttering, obesity), the disturbance is unrelated or out of proportion to it If the fear is restricted to speaking or performing in public, diagnosis should specify “performance only.” Other diagnostic features of SAD include [2]: • Post-event processing: Tendency to replay social encounters in a negative, self-critical manner • Attentional bias: Heightened attention to negative evaluative threat cues and lack of attention to positive or benign cues • Social skills deficits: Poor eye contact, closed stance, quiet tone of speech, and difficulties initiating conversations Patients with SAD highly inflate perceived social costs from committing hypothetical blunders. Accounting for much of this social cost inflation are concerns about revealing self-flaws and, in particular, concerns over appearing socially incompe- tent [117]. SPECIFIC PHOBIA Specific, simple, or isolated phobia describes excessive or unreasonable fear in the presence of phobic stimuli, typically involving specific animals, objects, or situations (e.g., dentists, spiders, elevators, flying, seeing blood). Phobic stimuli are either avoided or are endured with significant personal distress
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