Ad appearing in the American Journal of Psychiatry (August 2003)
Last month, in a letter published in the American Journal of Psychiatry, three researchers argued that it was now “appropriate” that “social anxiety disorder [be made] the official diagnostic label in DSM-5.” The disorder is currently listed in DSM-IVTR as “300.23 Social Phobia (Social Anxiety Disorder),” and since at least the year 2000, when one of the same psychiatrists published a similar letter in the Archives of General Psychiatry hoping to influence that particular edition, attempts have been made to reverse the order of the terms, even to drop the “social phobia” part entirely.
“The essential feature of Social Phobia,” begins the DSM-IVTR description, “is a marked and persistent fear of social or performance situations in which embarrassment may occur” (450). The embarrassment may be “situationally bound or situationally predisposed,” making diagnosis possible in either case, but the key element is that “the individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.” Identifying scenarios include public-speaking anxiety as well as eating, drinking, and even writing in public “because of a fear of being embarrassed by having others see their hands shake” (451).
As public-speaking anxiety is of course widespread in the general population and self-reported shyness, according to two Stanford psychologists, affects “nearly 50% (48.7% +/- 2%)” of North Americans (Henderson and Zimbardo), one has to ask why such run-of-the-mill fears are listed in the psychiatric manual in the first place. Over the years, repeated DSM task forces have added common fears and behaviors that dramatically lowered the disorder’s diagnostic threshold, greatly increasing both its prevalence rates and the risk of misdiagnosis among those with mild-to-serious shyness. Signs of “marked distress” in SAD, according to the manual, now include concern about saying the wrong thing—a fear at some point afflicting almost everyone on the planet.
Yet though the current edition of the DSM now includes, as signs of SAD in children, “freezing,” “clinging,” and “shrinking,” as well as merely the “appear[ance of being] excessively timid” (despite warning readers not to confuse SAD with shyness), and it diagnoses adults who merely “fear social situations” providing they recognize that fear as “excessive or unreasonable” (451), the current letter writers, Laura C. Bruce, Richard G. Heimberg, and Meredith E. Coles, are worried that “the impairment associated with the disorder” has led, incredibly, to its “minimization.” Apparently, its diagnostic criteria are insufficiently expansive and need widening even more.
The letter is a textbook example of how, using loaded terms such as “minimization,” researchers adjust and expand a disorder first stipulated as “chronic” until its diagnostic bar is set so low that almost anyone could trip over it.
“Using data collected from a telephone survey of residents of New York State,” the letter writers continue, “we investigated whether the disorder name affects the perceived need for treatment. Random-digit dialing was used to obtain phone numbers … In total, 806 people participated.”
“Respondents heard a brief vignette describing a person who experiences discomfort in social situations and often avoids social events. These symptoms were labeled as either social phobia or social anxiety disorder, and respondents indicated whether the person should seek mental health treatment.”
The results are dubious to say the least. “Fifty-eight respondents either replied that they did not know (N=40) or declined to answer (N=18). Of the remaining 748 respondents, 83.2 percent believed the symptoms labeled as social anxiety disorder warranted treatment compared with 75.8 percent who believed that symptoms labeled social phobia warranted treatment.”
Of course, one way of viewing this would be to say that on the basis of such sketchy descriptions, 75-83 percent of the respondents were willing to award a DSM diagnosis at all, something we might find most revealing and troubling.
But far from concluding that the general public is overly willing to assume that the shy and introverted have psychiatric disorders, the letter writers conclude: “These findings are encouraging. Despite a slightly greater likelihood of recommending treatment for social anxiety disorder, the overwhelming majority of respondents endorsed seeking help regardless of diagnosis name.”
“Our findings,” they add of the mere 7.4 percent difference between their two sets of respondents, “suggest that using the term ‘social anxiety disorder’ increases the likelihood that the condition will be perceived as requiring treatment.” In short, they wrote the American Journal of Psychiatry to argue that the reaction of just 55 random New Yorkers to a phone questionnaire offering “brief vignettes” of social anxiety should determine whether the psychiatric ailment is renamed.
More than a textbook example of “diagnostic bracket creep,” Peter Kramer’s term, where psychiatrists endlessly shift the goalposts, settling on one set of diagnostic criteria only to argue later that they grossly “minimize” the condition, the letter demonstrates that the DSM warning not to confuse SAD with shyness is itself completely meaningless: the examples and vignettes in the manual alone repeatedly muddle the two phenomena, making it almost impossible to distinguish between them.
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American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revised. Washington, D.C.: American Psychiatric Association.
Henderson, Lynne, and Philip Zimbardo (in press) “Shyness.” Encyclopedia of Mental Health. San Diego: Academic Press.
Lane, Christopher. 2007. Shyness: How Normal Behavior Became a Sickness. New Haven: Yale University Press.
Liebowitz, Michael R; Richard G. Heimberg; David M. Fresco; John Travers; and Murray B. Stein. 2000. “Social Phobia or Social Anxiety Disorder: What's in a Name?" Arch. Gen. Psychiatry 57 (2):191-92.