Cases That Test Your Skills

A showdown with severe social phobia

Author and Disclosure Information

Fears of interacting with other people were taking an ever-increasing toll on Mr. I. Drawing from a small but growing body of evidence, these doctors try to help this patient regain control of his life.



History: Living in fear

Mr. I, 41, presents for an initial psychiatric evaluation. He saw a psychologist 8 years ago for a “mild depression,” which he described as a lack of motivation and difficulty concentrating. His mood has been chronically “flat” for the last 10 years. He complains of poor energy and decreased sleep because of irregular work hours, and admits to using over-the-counter caffeine pills to help him function.

The patient denies suicidal ideations, symptoms of guilt, psychotic symptoms, or crying spells, but has a history of alcoholism and cocaine abuse. (He has been sober for 5 years.) Significant recent stressors include a recent breakup with his girlfriend, which he adds “really hasn’t bothered me at all.”

Mr. I has been increasingly avoiding social situations. Though he denies having panic attacks, interaction with other people triggers shortness of breath and chest tight-ness, especially when speaking in public to strangers.

The fear of what others might think of him is dominating Mr. I’s life. For example, he would like to console a housemate whose mother died, but because he is afraid of how the friend will react, Mr. I has not approached him. He adds that he goes out of his way to avoid contact with his co-workers, working irregular hours and eating his lunch in his car rather than the office lounge—even in inclement weather.

Mr. I does attend Alcoholic Anonymous meetings, but often sits toward the back. He had led some meetings, but refused to even look up from the podium while doing so. His anxiety worsened, his heart rate increased, and his palms sweated while leading the group. He began attending different AA meetings so that others would not recognize him and volunteer him to lead.

He adds that he feels comfortable meeting and dating women, since these exchanges are “scripted.” As he gets to know his partner better, however, Mr. I becomes more self-conscious.

Which of Mr. I’s symptoms would you address first: the depressive or the phobic?

Drs. Yu’s, Gordon’s, and Maguire’s observations

Based on Mr. I’s presentation, one might at first diagnose major depressive disorder, but chronic avoidance patterns differentiate his illness from an endogenous depression. Mr. I was diagnosed as having social phobia, a disorder that has been gaining attention among researchers.

A phobia is defined as an irrational fear that produces conscious avoidance of the feared subject, activity, or situation. The presence or anticipation of the phobic entity elicits severe distress, though the affected person usually recognizes that the reaction is excessive. DSM-IV defines social phobia as a strong, persisting fear of potentially embarrassing situations (Box).1

Two peaks of onset have been described: one occurring before age 5, and the other between ages 11 and 17.2 The mean age of onset has been reported to be 15.2


  1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
  2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situational or predisposed panic attack.
  3. The person recognizes that the fear is excessive or unreasonable.
  4. The feared social or performance situations are avoided, or else endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational or academic functioning, or social activities or relationships with others, or there is marked distress about having the phobia.
  6. In individuals younger than 18, the duration is at least 6 months.
  7. The fear or avoidance is not caused directly by a substance (e.g., a drug of abuse or medication) or general medical condition, and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).
  8. If a general medical condition or other mental disorder is present, the fear in criterion A is unrelated to it (e.g., the patient does not fear stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa). Specify if:

SOURCE: DSM-IV-TR. Washington, DC: American Psychiatric Association, 2000.

DSM-IV describes two types of social phobia: generalized social phobia and performance phobia. Normal fear and shyness should be differentiated from social phobia. Medical conditions—including CNS tumors and cerebrovascular diseases—and drugs typically bring about neurologic and mental status symptoms that can confound the diagnosis.

Next Article: