Generalized Social Phobia Versus Avoidant Personality Disorder A Commentary on Three Studies Thomas A. Widiger University of Kentucky ABSTRACT The findings of Herbert, Hope, and Bellack (1992) , Holt, Heimberg, and Hope (1992) , and Turner, Beidel, and Townsley (1992) are largely consistent. Avoidant personality disorder and generalized social phobia appear to be overlapping constructs that have only minor differences with respect to severity of dysfunction. This commentary addresses the implications of the findings with respect to the validity of the categorical distinction in the Diagnostic and Statistical Manual of Mental Disorders (rev. 3rd ed.; American Psychiatric Association, 1987 ) between avoidant personality and generalized social phobia, revisions of their respective diagnostic criteria, and their reclassification as either an anxiety or a personality disorder. Methodological and substantive suggestions for future research are also discussed. Correspondence may be addressed to Thomas A. Widiger, Department of Psychology, University of Kentucky, 115 Kastle Hall, Lexington, Kentucky, 40506-0044. Received: September 4, 1991 Revised: October 1, 1991 Accepted: October 3, 1991 The placement of the personality disorders on a separate axis in the American Psychiatric Association's revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM—III—R ; American Psychiatric Association, 1987 ) has contributed to substantial interest in the validity of the distinction between the personality disorders and various clinical syndromes ( Gorton & Akhtar, 1990 ). It is stated in the introduction to DSM—III—R that "there is no assumption that each mental disorder is a discrete entity with sharp boundaries (discontinuity) between it and other mental disorders" ( American Psychiatric Association, 1987 , p. xxii), but this denial is belied by the fact that in practice the DSM—III—R is used by clinicians and researchers to provide categorically distinct mental disorder diagnoses ( Carson, 1991 ). Whether a person who is suffering from social inhibitions is diagnosed as having a personality or an anxiety disorder can have considerable clinical, social, and professional repercussions (e.g., in treatment decisions, insurance coverage, and research funding; Frances, Pincus, Widiger, Davis, & First, 1990 ). Most social, clinical, forensic, and research agencies use the DSM—III—R , and the DSM—III—R makes categorical distinctions. The appearance in the Journal of Abnormal Psychology of three independent studies on the validity of the distinction between generalized social phobia (GSP) and avoidant personality disorder (APD) by Herbert, Hope, and Bellack (1992) , Holt, Heimberg, and Hope (1992) , and Turner, Beidel, and Townsley (1992) attests to the theoretical and clinical importance of this particular differential diagnosis. GSP is a subtype of social phobia wherein the person is fearful of most social situations (which often begins in late childhood or early adolescence); APD is a subtype of personality disorder Journal of Abnormal Psychology © 1992 by the American Psychological Association May 1992 Vol. 101, No. 2, 340-343 For personal use only--not for distribution. Page 1 of 712/4/2000http://spider.apa.org/ftdocs/abn/1992/may/abn1012340.htmlwherein the person exhibits a pervasive pattern of social discomfort, fear of negative evaluations, and timidity (which begins by early adulthood; American Psychiatric Association, 1987 ). Collectively and individually, the studies by Herbert et al., Holt et al., and Turner et al. provide a particularly informative empirical evaluation of this difficult and controversial differential diagnosis. This commentary was requested by the Editor of the Journal of Abnormal Psychology to facilitate their comparison, integration, and consideration for future research. I discuss in particular the implications of the findings with respect to the validity of the DSM—III—R distinction between APD and GSP, a revision of the diagnostic criteria, a reclassification of either APD or GSP, and future research. Is the DSM—III—R Distinction Between Generalized Social Phobia and Avoidant Personality Disorder Valid? The findings were largely consistent across the three studies. There were many cases of GSP without APD but few cases of APD without GSP. The studies by Holt et al. (1992) and Turner et al. (1992) may have been biased against finding APD cases without GSP because only persons with overt anxiety disorder symptomatology are likely to attend an anxiety disorders clinic. However, this bias did not occur in Herbert et al. (1992) , as their subjects were solicited through media advertisements for persons who were troubled by extreme shyness and social anxiety. Future studies may identify more cases of APD without GSP, but it is apparent by simply reading the DSM—III—R criteria for APD that these cases will be rather infrequent. As Turner et al. indicated, three of the DSM—III—R APD criteria explicitly involve GSP symptomatology: (a) avoidance of social or occupational activities that involve significant interpersonal contact, (b) reticence in social situations because of a fear of saying something inappropriate or foolish, and (c) fearful of being embarrassed by blushing, crying, or showing signs of anxiety in front of other people ( American Psychiatric Association, 1987 ). Given that the DSM—III—R also specifies that GSP will typically appear in late childhood or early adolescence and tends to be chronic thereafter ( American Psychiatric Association, 1987 ), it is evident that most persons who are diagnosed with APD will also be diagnosed with GSP (particularly those with the APD criteria of reticence in social situations and fears of being embarrassed, as suggested by the findings of Holt et al., 1992 ). All three studies did find significant differences between the GSP subjects with and without APD, and Holt et al. (1992) concluded that "the separate determination of [a GSP] subtype and presence of APD appears to have heuristic value among social phobia patients" (p. 323). However, the authors of all of these studies appear to be more impressed by the lack of either substantial or qualitative distinctions between GSP and APD. Turner et al. (1992) suggested that "the generalized subtype and APD groups are more similar than they are different" (p. 330). "These data suggest that on the basis
View Full Document
Unlocking...