Shy of a Phobia

Christopher Lane, author of the new book Shyness: How Normal Behavior Became a Sickness, argues in a New York Times op-ed piece that psychiatrists should stop pathologizing and medicating shy children. Instead, he says, they should restrict themselves to pathologizing and medicating really shy children:

It may seem baffling, even bizarre, that ordinary shyness could assume the dimension of a mental disease. But if a youngster is reserved, the odds are high that a psychiatrist will diagnose social anxiety disorder and recommend treatment.

Lane, a professor of English at Northwestern University, attributes the problem to "the diagnostic criteria for shyness" in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, which he says "are far from clear." According to the 1980 edition, Lane writes, someone could be diagnosed with "social phobia" if "he was afraid of eating alone in restaurants, avoided public restrooms or was concerned about hand-trembling when writing checks." The 1987 edition "expanded the list of symptoms by adding anticipated concern about saying the wrong thing, a trait known to just about everyone on the planet." The solution, Lane says, is to "reconsider the diagnostic standards" so as to "carefully distinguish normal—even healthy—shyness from social anxiety disorder." 

Far be it from me to defend the APA, but the definition of social phobia (a.k.a. social anxiety disorder) in the 2000 edition of the DSM requires "marked and persistent fear of one or more social situations" that the individual himself recognizes as "excessive or unreasonable" and that "interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships" or causes "marked distress about having the phobia." It's pretty clear that the condition is supposed to go beyond "ordinary shyness," although there's a lot of room for interpretation, especially when a psychiatrist is dealing with a child who may not be adept at reflecting on his own feelings and behavior.

But tinkering with the diagnostic criteria misses the point. The problem is not that psychiatrists are overdiagnosing social anxiety disorder; it's that social anxiety disorder is whatever psychiatrists say it is. As with almost all the other "disorders" listed in the DSM, there is no underlying biological condition that can be measured objectively, despite all the talk about using SSRIs such as Prozac and Zoloft (the preferred treatment for social phobia) to correct hypothesized chemical imbalances in the brain. Indeed, the fact that so-called anti-depressants are used to treat a wide variety of conditions, and actually seem to be more effective at relieving anxiety than they are at relieving depression, suggests the DSM's behavior-based taxonomy does not reflect clear etiological distinctions.

People with crippling fear of social situations should be free to seek help from psychiatrists, including drugs that help them function better. Parents should be free to seek such help for their children. But hasty use of SSRIs might be avoided if we stopped seeing such social anxiety as a disease akin to cancer or tuberculosis, where a physical process can be identified and treatment recommended on that basis. A social phobia diagnosis is nothing more than one person's opinion that a given individual's shyness is extreme. Differences of opinion about such matters, unlike differences of opinion about whether someone has cancer or tuberculosis, cannot be conclusively resolved, even by a new, improved DSM.