A Case of Mis-categorization of Different Psychopathological Domain

Social anxiety is mainly defined as a noticeable and constant fear of one or more social or performance circumstances in which the individual is exposed to unknown people or possible inspection by others. The individual fears that he or she will behave in a way that will be humiliating. These fears lead people with social anxiety to keep away from all or some social situations and in utmost cases this could lead to complete social isolation. Regardless of high prevalence, social anxiety disorder has not been broadly investigated and the activities that underlie its disclosure in psychosis remain unspecified. The main link between social anxiety distress and positive psychotic symptoms, particularly paranoia, is not yet clarified.¹

A 30-year-old male patient presented with chief complaints of fearfulness in the form that he became fearful of people and suspiciousness in the form that he felt that whenever he sees any two individuals, he thinks that they are talking about him which were followed by panic like episodes which were associated with palpitations, perspiration, dizziness. He was avoiding social gathering or involved with distress. He is a teacher so going to school was also difficult because of ” fear of People” he also complained of irritability with anger out episodes, anxious mood, decreased communication, anhedonia, crying episodes. He consulted a psychiatrist and was prescribed Tab. Amisulpride 400mg/day, Tab. Aripiprazole 20mg/day, Tab. Olanzapine 10mg/day, Tab. Clozapine 100mg/day, Tab. Trifluoperazine 10mg/day+ Tab. Trihexyphenidyl 4mg/day, Tab. Alprazolam 1.5mg/day, Tab. Lorazepam 2mg/day, Tab. Clonazepam 0.5 mg/day and Tab. Propranolol 40mg/day. He took these medications but didn’t improve and used to sleep all throughout the day and would only wake up to take meals. During this period, he used to go to school to teach children but would only go for 1-2 hr. He continued the medications for 5-6 years on his own sometimes with only 1 follow up from the psychiatrist because he was getting sleep and avoided interactions with the people. After that he visited us and was admitted and detailed evaluation was done. Routine investigations were done and detailed psychiatric history was taken and MSE was done. On detailed evaluation during history taking, it was noted that his symptoms of fearfulness and suspiciousness were actually fear of going in public as he used to think that people are talking that he is inferior to them and that people might misjudge him or underestimate him. On detailed Mental Status Examination, it was noted that he suffered from social anxiety with avoidant behavior. His previous medications were tapered off and he was examined with Social Anxiety Disorder (SAD). He was given Tab. Sertraline 100mg/day, Tab. Amoxapine 100mg/day, Tab. Trifluoperazine 5mg/day+ Tab. Trihexyphenidyl 2mg/day, Tab. Propranolol 40mg/day, Tab. Lorazepam 2mg/day. He gradually reported improvement within 1 month by 70% for the very first time and was able to go out in public without any fear. But after 2 months he started having symptoms of excessive spending of money, excessive familiarity with strangers, increased goal directed activity, talk of high matter for which lithium was added to his medications but he reported no improvement.

It depends on the individual’s capacity or incapacity to challenge the suspicion of being condemned by people. Another explanation would be that social anxiety is caused primarily due to affective disturbance, instead of a thought abnormality. Due of the self-consciousness, teamwork would cause particular concern and discomfort, thus the individual begin to develop an avoidant or remote personality. Affective and psychotic phenomena often co-occur, and such a co-occurrence forecasts a poorer course and outcome.² In our case report, we found that the individual is suffering from panic episodes, anger episodes and irritability. Thus, with greater perseverance of schizotypal and negative symptoms, more illness behaviour and more evidence of familial responsibility for mental illness. Another predisposing point in few patients with SA is the examination of bipolar-like progression. It specifies the possibility not only of hypomanic episodes but also of manic episodes with psychotic symptoms. We also discovered that antipsychotics did not give rise to remarkable improvement.³

We conclude that, it is requisite to categorize the symptoms into clinically relevant domain by detail history taking and MSE. These patients were more probable to report anxiety and unlikely to account formal thought impairment than patients with psychotic spectrum disorder.⁴ The disparity between delusion and anxious distress may be imprecise and can possibly change throughout the disorder’s evolution. Therefore, new diagnostic subcategories or the growth of the social anxiety diagnostic is required to get the better the current diagnostic imprecision. There appears to be a characteristic spectrum between SAD and DDs.⁵

The authors are sincerely thankful to all the members of Department of Psychiatry, Dhiraj Hospital and Department of Pharmacy, Sumandeep Vidyapeeth Deemed to be University (SVDU) for their support.