Social and Specific Phobias: Assessment

Assessment

Special Issues in Psychiatric Examination and History

During all parts of the initial evaluation, the psychiatrist should be sensitive to several issues. First, for many patients with pho-bias, even discussing the phobic object can provoke anxiety. For example, some patients with spider phobias experience panic at-tacks when they discuss spiders. Some patients with blood pho-bias faint when they discuss surgical procedures. Therefore, the psychiatrist should ask the patient whether discussing the phobic object or situation will provoke anxiety. If the interview is likely to be a source of stress, the psychiatrist should emphasize the importance of the information that is being collected, as well as the potential therapeutic value of discussing the feared object. As described in a later section, exposure to the feared stimulus is an essential component of the treatment of most specific pho-bias. Of course, the interviewer should use his or her judgment when deciding how much to push the patient in the first session. For treatment to be effective, establishing trust in the psychiatrist early in the course of treatment is essential.

With respect to social phobia, the assessment itself may be considered a phobic stimulus. Because individuals with social phobia fear the evaluation of others, a psychiatric interview may be especially frightening. Even completing self-report question-naires in the waiting room may be difficult for patients who fear writing in front of others. The psychiatrist should be sensitive to this possibility and provide reassurance when appropriate.

Structured and Semistructured Interviews

Although there are numerous structured and semistructured in-terviews available, two of the most commonly used interviews for diagnosing anxiety disorders are the Anxiety Disorders In-terview Schedule for DSM-IV (ADIS-IV) (Brown et al., 1994) and the Structured Clinical Interview for Axis I DSM-IV-TR Disorders-Patient Edition (SCID-I/P for DSM-IV-TR) (First et al., 2001). Current and lifetime diagnoses of specific phobia and social phobia based on the ADIS-IV have been shown to have good to excellent reliability for the specific phobia types and the generalized type of social phobia. Each interview has advantages and disadvantages. Although the SCID-I provides detailed assessment of a broader range of disorders relative to the ADIS-IV (including eating disorders and psychotic disor-ders), the ADIS-IV provides more detailed information on each of the anxiety disorders and, like the SCID-I, includes sections to provide DSM-IV diagnoses for the mood disorders and other disorders that are typically associated with the anxiety disorders (e.g., substance use and somatoform disorders). In addition, the ADIS-IV includes more questions to help differentiate specific and social phobias from other disorders with which they share features.

Self-report Measures

Numerous self-report measures have been created for the assess-ment of specific phobias and social anxiety. The main advantage of self-report measures is the time that they save for the psychia-trist. Relevant self-report measures are recommended before the clinical interview if possible. This will allow the interviewer to follow up specific responses during the interview. Measures can be administered again, periodically, to assess progress and out-come. It should be noted that questionnaire measures do not al-ways correlate highly with performance on behavioral measures. Furthermore, there is evidence that men are more likely than women to underestimate their fear on specific phobia measures. The most common questionnaires used to screen for specific phobias are the various versions of the Fear Survey Schedule. In addition, a variety of measures exist to assess fear of specific objects and situations. For example, the Mutilation Question-naire (Klorman et al., 1974) is among the most common tests for assessing fear of situations involving blood and medical pro-cedures. Self-report measures for assessing both specific phobia and social anxiety are listed in Table 50.1.

Behavioral Tests

Behavioral testing is an important part of any comprehensive evaluation for a phobic disorder. This is particularly the case if behavioral or cognitive–behavioral treatment will be used. Because most individuals with phobias avoid the objects and situations that they fear, patients may find it difficult to describe the subtle cues that affect their fear in the situation. In addition, it is not unusual for patients to misjudge the amount of fear that they typically experience in the phobic situation. A behavioral approach test can be useful for identifying specific fear triggers as well as for assessing the intensity of the patient’s fear in the actual situation.

To conduct a behavioral approach test, patients should be instructed to enter the phobic situation for several minutes. For example, an individual with a snake phobia should be instructed to stand as close as possible to a live snake and note the specific cues that affect the fear (e.g., size of snake, color, movement) and the intensity of the fear (perhaps rating it on a 0–100-point scale). Patients should pay special attention to their physical sensations (e.g., palpitations, sweating, blushing), negative thoughts (e.g., “I will fall from this balcony”) and anxious coping strategies (e.g., escape, avoidance, distraction).

The behavioral approach test will help in the develop-ment of a specific treatment plan. However, before treatment patients will often be reluctant to enter the feared situation. If this is the case, the information collected during the behavioral approach test may be elicited during the early part of behavioral treatment.

Differences in Sex, Cultural and Developmental Presentation

Sex Differences

As mentioned earlier, specific phobias tend to be more common among women than men. This finding seems to be strongest for phobias from the animal type, whereas sex differences are smaller for height phobias and blood-injury-injection phobias. In addition, social phobia tends to be slightly more prevalent among women than men, although these differences are rela-tively small.

There are several reasons why women may be more likely than men to report specific phobias. First, men tend to underreport their fear. Also, women may be more likely than men to seek treatment for their difficulties, which would account for the fact that sex differences are often larger in treatment samples compared with epidemiological samples. In addition sex ratios for phobias differ across cultures, which may be explained by cultural differences in treatment seeking. Finally, the sex differ-ence in prevalence may reflect actual differences between men and women in susceptibility to develop phobias.

Women and men are taught to deal differently with typi-cal phobic stimuli. Traditionally, boys more than girls are often encouraged to play with spiders and toy snakes and to engage in more adventurous activities (e.g., hiking in high places). In ad-dition, women may have more role models for the development of fear than do men. Images of women standing on chairs when they see a mouse or running away from spiders are common in children’s cartoons and other media, but men are rarely depicted as being frightened by these objects. Therefore, it is possible that in Western cultures women learn to fear certain situations more strongly than do men. Of course, it is difficult to know whether culture and the media are responsible for sex differences or sim-ply reflect differences that exist for other reasons (e.g., different predisposing factors). It will be interesting to see whether sex ratios for phobias change as traditional gender roles continue to change

Cultural Differences

Little is known about cultural differences in specific and social phobias. Nevertheless, a few studies bear on the issue of cultural differences in phobias. For example, there is evidence from epi-demiological studies that African-Americans are 1.5 to 3 times as likely as whites to report phobic disorders, even after controlling for education and socioeconomic status. Several explanations for this finding have been provided. For example, some of the fears reported by African-American individuals may reflect realistic concerns that were misdiagnosed as phobias. For example, Afri-can-American persons in inner city communities may have more realistic reasons to fear violence. Furthermore, African-Ameri-cans experience more negative evaluation from others, and some of their social concerns may be realistic. Another possibility is that African-Americans experience more chronic stress than whites and therefore may be more susceptible to the development of phobias and other problems. Finally, there may be cultural dif-ferences in response biases on questionnaire measures of fear and during interviews.

Research has found that specific phobias, but not social phobias, are more common among US-born Mexican-Americans than in US-born whites or immigrant Mexican-Americans, after controlling for sex, age, socioeconomic status and various other variables. A variety of studies have shown that specific phobias, social phobia and related conditions exist across cultures. For ex-ample, in Japan, a condition exists called taijin kyôfu in which in-dividuals have an “obsession of shame”. This condition has much overlap with social phobia in that it is often accompanied by fears of blushing, having improper facial expressions in the presence of others, looking at others, shaking and perspiring in front of others. In addition, studies have identified individuals with so-cial and specific phobias in a variety of other nonWestern coun-tries including Saudi Arabia, India, Japan and other East Asian countries. Interestingly, in some other cultures, the sex ratio forphobias tends to be reversed. For example, in studies from Saudi Arabia and India, up to 80% of individuals reporting for treat-ment of phobias were male.

Psychiatrists treating patients from different cultures should be aware of cultural differences in presentation and re-sponse to treatment, such as cultural differences in verbal com-munication styles, proxemics (i.e., use of interpersonal space), nonverbal communication and other verbal cues (e.g., tone and loudness). Many cues that a psychiatrist might use to aid in the diagnosis of social phobia in white Americans may not be use-ful for diagnosing the condition in other cultures. For example, although many psychiatrists interpret a lack of eye contact as indicating shyness or a lack of assertiveness, avoidance of eye contact among Japanese and Mexican-Americans is often viewed as a sign of respect. In contrast to white Americans, Japanese are apparently more likely to view smiling as a sign of embar-rassment or discomfort. Furthermore, cultural differences in tone and volume of speech may lead psychiatrists to misinterpret their patients. For example, whereas white Americans are often un-comfortable with silence in a conversation, British and Arab in-dividuals may be more likely to use silence for privacy and other cultures use silence to indicate agreement among the parties or a sign of respect. In addition, Asian individuals have been reported to speak more quietly than white Americans, who in turn speak more quietly than those from Arab countries. Therefore, differ-ences in the volume of speech should not be taken to imply differ-ences in assertiveness or other indicators of social anxiety.

Treatment methods may have to be adapted for different cultures. For example, the direct style of many cognitive and be-havioral therapists may be more likely to be perceived as rude or insensitive by individuals with certain cultural backgrounds than those with other backgrounds. It should be noted that individu-als within a culture differ on these variables just as individuals across cultures differ. Therefore, although psychiatrists should be aware of cultural differences, these differences should not blind the psychiatrist to relevant factors that are unique to each individual patient.

Developmental Differences

Among children, specific and social fears are common. Be-cause these fears may be transient, DSM-IV-TR has included a provision that social and specific phobias not be assigned in children unless they are present for more than 6 months. In addition, children may be less likely than adults to recognize that their phobia is excessive or unrealistic. The specific ob-jects feared by children are often similar to those feared by adults, although children may be more likely to fear objects and situations that are not easily classified in the four main specific phobia types in DSM-IV-TR (e.g., balloons or costumed char-acters). In addition, children often report specific and social phobias having to do with school. Children with social phobia tend to avoid changing for gym class in front of others, eating in the cafeteria, or speaking in front of the class. They may stay home sick on days when frightening situations arise or may make frequent trips to the school nurse. Whereas some investigators have found that boys and girls are equally likely to present for treatment of phobias, others have found social phobia to be more common among girls. In one prospective study of childhood anxiety disorders, Last and colleagues (1996) found that almost 70% of children with a specific pho-bia were recovered over a 3- to 4-year period compared with arecovery rate of 86% for social phobia. Thus, almost a third of the clinical sample with specific phobia had symptoms that still met clinical criteria for specific phobia at the end of the follow-up period. This was the lowest recovery rate among the anxi-ety disorders that were studied. However, those in the clinical sample with specific phobia had the lowest rate of development of new psychiatric disorders (15%) compared with the other anxiety disorders studied (e.g., the rate of development for new psychiatric disorders was 22% for those in the clinical sample with social phobia).