Differentiating the subtypes of social anxiety disorder

Abstract

Since the inclusion of subtypes of social anxiety disorder (SAD) in the DSM-III-R, the most studied have been generalized versus specific subtypes. Previous research indicated that the generalized subtype was associated with greater severity, comorbidity and functional impairment compared to the specific subtype, but more recent evidence supports a dimensional conceptualization of SAD. Earlier studies also possessed limitations, such as heterogeneity in definitions of generalized SAD. Based on the more recent findings and the limitations of the earlier studies, the DSM-5 eliminated the generalized specifier. However, it also retained a categorical system by including a performance-based fear specifier, thus leaving an open debate on whether or not a dimensional or categorical system best describes SAD. Future research could examine other, more recent concepts as potential subtypes (e.g., attentional biases), or perhaps the larger question of the overall utility in subtyping SAD.

Keywords::

• assessment
• diagnosis
• social phobia
• social fears
• subtype
• treatment

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • DSM diagnostic criteria for social anxiety disorder (SAD) and SAD subtypes have changed significantly over time, from viewing SAD as a predominantly circumscribed performance fear to more recently a heterogeneous category comprised of a broader range and combination of fears.

• • Prior studies on the DSM-IV subtypes of generalized and specific suggest that they may differ on various characteristics, such as prevalence, severity, comorbidity, morbidity, behavioral and physiological responses to social tasks, familial transmission and to a lesser extent, perhaps treatment outcomes.

• • However, these prior studies possessed limitations including variability in the definition of subtypes across researchers, and not accounting for overall severity of SAD. Studies have found that when accounting for overall severity, few differences exist.

• • Based on these concerns and newer data supporting a dimensional system, the DSM-5 has eliminated the generalized specifier. However, the DSM-5 now includes a performance-based specifier based on newer evidence suggesting that individuals with performance only fears differed from individuals with multiple fears.

• • Currently, individuals with a more generalized form of SAD may be more likely to receive selective serotonin reuptake inhibitors or other standing-dose medications, a combination of medication and psychotherapy, and longer durations of treatment compared to those with circumscribed fears. However, the research to date on treatment outcomes and subtypes included a limited number of patients with the specific subtype relative to the generalized subtype, thereby limiting the conclusions that can be drawn.

• • Despite the extensive focus on generalized and specific subtypes, concepts that potentially could serve as alternative subtypes have been explored and perhaps could continue to be explored in future research (e.g., attention bias or interpersonal subtypes). Nonetheless, the larger issue remains as to whether subtyping at all would serve a useful function.

• • Prior studies on treatment response depending on subtypes have shown a few differences, but these studies have been limited due to small samples. Rather than continuing to examine outcomes, future research should examine mechanisms of change and whether that differs among various presentations of SAD.

• • It is expected that, given the recent research findings, the conceptualization of SAD will continue to move towards a dimensional rather than categorical system.