重症 社會恐怖症과 精神分裂病의 鑑別診斷

Differential Diagnosis Between Social Phobia and Schizophrenia

This is a report on six clinical cases of severe social phobia misdiagnosed as schizophrenia in the past, with an aim at differentiating the diagnostic criteria between schizophrenia and social phobia. Briefly, the grounds for diagnosing them as schizophrenia in the past were􀆮 onset age at adolescence, avoiding interpersonal relationship, bizarre delusional perception, etc. A t present, however, after 10 years of being diagnosed as schizophrenia, they show no signs of personality deterioration, intact reality testing, and all of them experiencing social phobic symptom prior to schizophrenia break in the past and at present as well. It is for these reasons that the diagnostic validity of the six cases was reconsidered.The followings are points which make the study group different from schizophrenia: 1. Premorbid Personality􀆮 A ll but two cases were sociable and active in social affairs with above average academic grade, and showed leadership in school until the initial onset of social phobic symptom after which they gradually became withdrawn. 2. Age at onset: In general, shizophrenia and social phobia, show a relatively early age of onset at adolescence. However, the study groups symptoms appeared a little earlier (average 16 years old) than the usual onset age of schizophrenia. 3. Praecox Feeling: Although the praecox feeling is not a reliable criteria for schizophrenia, no such signs were noted in the study group. 4. Personality Deterioration and Regression􀆮 Noapparent signs were noted. Instead, all had a high school education including two college graduates which indicates their high aspiration for life in general. 5. Perceptual Disorder: Although study group shows schizophrenia-like perceptual disorders in the surface, upon close examination, distinct differences from schizophrenia were noted. As an example, the symptom of “emitting odor from my body” does not appear to be a hallucinatory experience as the patient cannot smell the odor himself. The patient knows intuitively through the gestures of others (i.e., blowing nose, covering nose, opening the window,etc.) that he makes others feel unpleasant and as a result, harm them. Therefore, the symptom appears only in the presence of others, thus, the symptom can be said to be a delusional perception rather than a full blown hallucination. 6. Issues on Identity􀆮 In schizophrenia, the patient’s total identity changes and is persecuted with or expelled into a pseudocommunity. Yet in social phobia, the patient’s problem is localized at specific parts of the body(i.e., eyes,nose) and is clearly aware of the reason why he/she is being avoided by others where as schizophrenia has no such insight 7. Delusion： In schizophrenia, delusion is persecutory in nature with a sense of hidden intention which is present everywhere and at all time. In contrast, the study group, delusional feelings take the from of harming others, thus, blaming himself and appears only in the presence of others. The delusions are never systemized and ideas of being controlled or influenced are also absent. 8. Affective Disturbance： Although no evidence of primary affective disturbance was noted in the study group, secondary depression was marked due to strong tendency of self-blame for harming others as evidenced in two cases of attempted suicide. 9. Interpersonal Relationship： Social phobics are withdrawn and avoid interpersonal relations for fear of making others uncomfortable with their presence and not due to their indifferent attitude as in the case of schizophrenia. 10. Understanding the meaning of symptom： As vague as it may appear, the meaning of social phobic symptoms in the study group are clear cut. In fact, social phobic symptoms the