Zoloft 2003/AJP
Source: Zoloft 2003/AJP

Updated: November 6, 2015 —

In a letter to the American Journal of Psychiatry, three researchers argued in May 2012 that it would be “appropriate” for social anxiety disorder to be made "the official diagnostic label in DSM-5.” The disorder had been 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 forthcoming edition as well, attempts were made to reverse the order of the terms, even to drop the “social phobia” part completely.

The researchers were successful on the second try. “The essential feature of Social Anxiety Disorder,” begins the DSM-5 description, “is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others." The previous edition had indicated, far more loosely, that "embarrassment may occur," which both editions indicate may be “situationally bound or situationally predisposed,” making diagnosis possible in either case. The key element, according to DSM-5, is that "the individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others)." Identifying scenarios include public-speaking anxiety as well as eating, drinking, writing, and even pointing in public, because of a fear of being embarrassed by having others see hands trembling.

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 were ever listed in the influential psychiatric manual in the first place. Over the years, repeated DSM task forces 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 latest edition of the manual, now include concern about saying the wrong thing—a fear at some point afflicting almost everyone on the planet.

Yet even though DSM-5 also includes, as diagnosable 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 allows diagnosis of adults who merely “fear social situations,” providing they recognize that fear as “excessive or unreasonable," the 2012 letter writers, Laura C. Bruce,  Richard G. Heimberg, and Meredith E. Coles, worried that “the impairment associated with the disorder” had led, incredibly, to its “minimization.” Apparently, its diagnostic criteria were insufficiently expansive and needed widening even more.

The letter is a textbook example of how, using loaded terms such as “minimization,” researchers can adjust and expand a disorder first stipulated as “chronic” until its diagnostic bar is set so low that almost anyone can trip over it.

“Using data collected from a telephone survey of residents of New York State,” the letter writers continued, “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 were 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 revealing and troubling.

Yet far from concluding that the general public was overly willing to assume that the shy and introverted have psychiatric disorders, the letter writers concluded: “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 added 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. They were successful.

More than a textbook example of “diagnostic bracket creep,” Peter Kramer’s term, where psychiatrists endlessly shift the goalposts, setting one set of diagnostic criteria only to argue later that they “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, making it almost impossible to distinguish between them.

christopherlane.org Follow me at @christophlane


American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, D.C.: American Psychiatric Association.

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 and Social Anxiety.” Social Anxiety: Clinical, Developmental, and Social Perspectives, 3rd ed. Chennai, India: Elsevie.

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.

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