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Social phobia in spasmodic torticollis: some conceptual issues
  1. P Sharma1,
  2. N Gupta1
  1. 1Department of Psychiatry, PGIMER, Chandigarh-160012, India
  1. Correspondence to:
 Professor N Gupta;
  1. H Gündel2,
  2. A O Ceballos-Baumann3
  1. 2Department of Psychosomatic Medicine, Klinikum rechts der Isar, TU München, Langerstr 3, 81675 München, Germany
  2. 3Department of Neurology, Klinikum rechts der Isar

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    Gundel et al1 tackle an important issue of social phobia (SP) in patients with spasmodic torticollis (ST). This is because social avoidance itself contributes to a significant degree of distress and dysfunction in patients with chronic medical conditions.2 Also, potentially beneficial pharmacological and psychosocial treatments remain undelivered because of under recognition of this problem. Keeping these aspects in mind, we would like to highlight certain conceptual and methodological issues.

    Firstly, the sample was restricted to patients with ST who required treatment with botulinum toxin. Also, the severity (Tsui) score for the sample has not been mentioned. Hence the sample may not be representative of all patients with ST.

    Secondly, life events were assessed for the one year period before the initial manifestation of ST. As per the authors the mean (SD) duration of illness, at time of assessment, was 11.9 (11.3) years. Although life events were reported in 50% of patients, yet caution should be exercised in relation to this result as elicitation of life events is associated with problems in recall, especially in illnesses of long duration.

    Thirdly, 80% of patients with SP were classified as reactive. Though the authors mention that social anxiety had occurred after onset of ST, they do not provide data on the duration of SP, and hence fail to demonstrate a temporal relation between onset of symptoms of SP and ST. Related to this is the issue of primary/secondary/tertiary psychiatric comorbidity. Comorbidity as a concept has different dimensions.3 As this classification is not followed in DSM- IV,4 it would be helpful if the authors provide essential details for a better understanding of the same. The authors postulate a subgroup of patients with SP who have symptoms of social anxiety secondary to ST—that is, presence of a probable cause-effect relation. But, this brief report fails to mention as to how this subgroup was identified. Indeed, as is known, to be classified as “organic psychiatric disorders”, certain diagnostic criteria need to be fulfilled in both ICD-10 5 and DSM-IV.4 Although SP may not be taken as “organic” in origin, yet labelling it as secondary to (or arising out of) ST requires further evidence.

    Fourthly, the authors make an important assertion that DSM-IV4 excludes patients with social anxiety secondary to medical conditions, and this is without empirical basis. In fact, there seems to be no place for such patients with social anxiety/phobia in DSM-IV. On the other hand, ICD-105 diagnostic criteria do not preclude against the diagnosis of SP in patients with physical conditions. It seems that ICD-10 is more broad based and less conservative than DSM-IV in terms of identifying various types of psychiatric morbidity in the physically ill. Hence, it may be more appropriate to use ICD-10 for such patients until the DSM classificatory system resolves this issue in greater detail with availability of the current empirical evidence.1

    Lastly, though the authors adopted a rigorous methodology for determination of diagnosis, yet it seems surprising that no patient was assessed for Axis II diagnosis; anxious–avoidant personality disorder (AAPD). AAPD is the most common differential diagnosis for SP and it has been shown that differentiating it from SP is difficult.4,6 Additionally, patients with SP can have premorbid anxious traits (or AAPD) making personality an important comorbid issue.6,7 This conceptual and diagnostic overlap needs to be kept in mind before giving a definitive diagnosis of SP as the treatment is influenced to a great degree by the diagnosis. Hence, there is a need to evaluate for an additional or alternative diagnosis of AAPD in patients with SP.

    Overall, although, this study provides a database on psychiatric morbidity, especially SP, in patients with ST but the conceptual issues related to diagnosis of SP need to be critically considered.


    Authors’ reply

    1. We agree with Sharma and Gupta in that our results are based on spasmodic torticollis (ST) patients treated with botulinum toxin, although in untreated patients social phobia may be even more severe. Cultural and other biases could also play a part. The mean Tsui Score of our sample was 7.58, SD 3.77, range 2–26.

    2. There is no perfect method for retrospectively measuring stressful life events. Data should therefore be interpreted with the appropriate caution. Because of the relatively small point prevalence ration of 5.4 per 100 000 in cervical dystonia,1 it would be methodologically virtually impossible to investigate this issue in a longitudinal study.

    3. We used the questions F41–F50 for the diagnosis of social phobia when conducting the SCID interview.2,3 If criteria A-G or A-H were met by a participant, she/he was additionally asked if these symptoms had initially occurred before or after the manifestation of ST and what had been the main reason for developing social phobia from the patients’ view. Based on the patient’s answer and the clinical judgment of the interviewer, social phobia was classified as reactive or not reactive to ST.

      We did include the data about the duration of social phobia in our data file when social phobia was diagnosed as the clinically most important psychiatric diagnosis. Of these n=48 patients (41.3%), the mean duration of ST was 12.4 (SD 10.8) years and the mean duration of social phobia was 11.2 years (SD 11.3). Within this sample of 48 patients, three patients reported an onset of social phobia before the onset of ST. Mean duration of social phobia in these three patients was 3, 33, and 38 years.

    4. In accordance with studies on social phobia in adult stutterers4,5 and essential tremor,6 we used DSM-IV criteria.3 ICD-10 does not preclude against the diagnosis of social phobia in patients with chronic somatic disease and thus may conveniently be used to classify this condition in patients with disfiguring or disabling physical conditions.

    5. The issue on anxious-avoidant personality disorder (AAPD) as differential diagnosis to social phobia is very interesting and should be explored in future studies. AAPD before the diagnosis of ST may indicate increased vulnerability of ST patients to develop social phobia or psychiatric disease.

      The points raised by Sharma and Gupta are valuable and should be taken into account in further research on the issue of social phobia in ST. Disturbed body image and negative self referent cognitions with the consequence of developing social phobia and/or a feeling of stigma are clearly a main psychological problem in a large subgroup of ST patients (see, for example, Papathanasiou et al7).


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