In Debate
Social Disadvantage Is Not Mental Disorder: Response to Campbell-Sills and Stein
Jerome C Wakefield, DSW, PhD1,
Allan V Horwitz, PhD2,
Mark F Schmitz, PhD3
(Can J Psychiatry 2005;50:324–327)
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Our target article argued that, although there are genuine social-phobic disorders wherein something goes wrong with mechanisms that generate social anxiety, most conditions satisfying DSM-IV social phobia criteria are likely not disorders but high-end, normal-range social anxiety overstimulated by contemporary social environments that demand high interaction and scrutiny while frowning on submission displays (1). We used the harmful dysfunction analysis of mental disorder to evaluate disorder status: according to this model, a disorder is a harmful failure of an internal mechanism to perform a natural function for which it was biologically designed. Social anxiety, we argued, is a normally distributed, biologically selected trait designed to protect individuals from risky behaviour in the social group. High-end designed levels of social anxiety may be less useful now than in ancestral environments—and even disadvantageous in current social environments—but such anxieties are part of normal human nature and not dysfunctions.
In their thoughtful defense of DSM criteria, Campbell-Sills and Stein (2) acknowledge that some community cases of DSM-defined social phobia are normal temperamental variation rather than disorders. Nonetheless, they defend the classification of most DSM social phobia as disorder. They argue that the harmful dysfunction analysis is inadequate for judging disorder; that, anyway, most DSM social phobia is harmful dysfunction; and that, regardless, DSM social phobia is best classified as disorder for pragmatic reasons. We consider these points in turn.
Objections to the Harmful Dysfunction Analysis
Campbell-Stills and Stein claim that the harmful dysfunction analysis cannot correctly classify asthma as a disorder because asthma is caused by a normal-range immune response acting on the lungs; thus there is no dysfunction. The harmful dysfunction analysis clearly does classify asthma as a disorder, but not because of immune system dysfunction. Asthma is roughly defined as a chronic inflammatory disease in which the airways in the lungs become blocked or narrowed, causing difficulty breathing. The inability of airways to move adequate air is manifestly a failure of designed function, and it is this dysfunction that makes asthma a disorder. Far from being a counterexample, asthma clearly illustrates the explanatory power of the harmful dysfunction analysis.
Campbell-Sills and Stein also object that the harmful dysfunction analysis concerns group benefits rather than individual needs. This reflects a misconception about evolutionary function: a trait spreads through groups, but only because the trait is advantageous for individuals. From the group objection, the authors mistakenly worry that the harmful dysfunction analysis overpathologizes socially disapproved conditions. To the contrary, the harmful dysfunction analysis specifically precludes such diagnosis unless there is dysfunction. The harmful dysfunction analysis, we believe, remains the most accurate and explanatory account of disorder.
Are DSM-IV Social Phobias Harmful Dysfunctions?
Campbell-Sills and Stein claim that most DSM-defined social phobia is disorder in the harmful dysfunction sense. They argue that “when mechanisms generating social anxiety are overactive, they do not minimize risk or allow for a normative range of social interaction” (2, p 321) and thus do not perform their function. However, “overactive” is not defined. Biologically high-normal temperament is overactive in an evaluative sense (like adolescents’ “overactive sex glands”), but it is not overactive in the medical sense and does allow for successful performance of functions in expectable environments, within a normal distribution of trade-offs of risk avoidance and social facility. Even if such anxiety is painful or currently socially undesirable, it does not entail dysfunction. In contrast, anxiety above the biologically selected range is indeed dysfunction and may undermine basic social functioning, but no evidence is offered that most DSM-defined social phobia involves overactivity in this sense.
Campbell-Sills and Stein observe that we critiqued DSM criteria singly, and they claim that the criteria taken together may still indicate dysfunction. However, the examples we used to critique each criterion implicitly took account of the others. As we showed, the DSM criteria can be simultaneously satisfied by 2 kinds of nondisordered cases: high-normal generalized social anxiety and intense nongeneralized anxiety specific to socially novel and naturally anxiety-triggering situations such as public speaking or stage performance before nonfamiliars.
Campbell-Sills and Stein’s basic argument seems to be as follows: high social anxiety interferes with being sociable; there are advantages to being sociable; therefore, high social anxiety is a disorder. However, this argument leads to the inappropriate pathologization of extensive domains of social and personal life; for example, it is socially disadvantageous to be discourteous, nonconformist, short, and unattractive. When society rewards social interactions that people are naturally designed to fear, that does not render disordered those naturally less talented at meeting such demands.
Beyond some fuzzy boundary, of course, loss of social-interactive capacity does constitute a dysfunction in biologically designed capabilities. We cannot present here an account of when normal-curve extremes become dysfunctions—a difficult problem for any account of disorder. However, we agree that, when social anxiety is so intense that it makes even relationships with intimates such as family members highly problematic; or when it renders an adult incapable of interacting with potential sexual partners, of taking necessary steps to procure employment, or of pursuing an education (where even nonscrutiny situations like sitting in a classroom provoke high anxiety), then social anxiety is clearly beyond the level designed to accomplish its adaptive functions and interferes with other basic functions. This is prima facie evidence of dysfunction according to standards of what humans need in almost any social environment (and not merely what is considered desirable in 21st century North America). Neither DSM-defined social phobia criteria nor Campbell-Sills and Stein’s arguments distinguish cases of such dysfunction from an enormously broader temperamentally anxious group who can adequately satisfy their needs by making some choices (for example, by choosing less socially stressful occupations or by not taking classes requiring much public speaking) or by giving up some desired outcomes—limitations that do not necessarily indicate dysfunction or disorder.
Campbell-Sills and Stein argue that our mass society requires interactions with nonfamiliars and thus “necessitates a habituation of the anxiety response once the organism has learned that a novel social situation is nonthreatening” (2, p 322), implying that failure of such habituation implies disorder. This argument is reminiscent of attempts to ignore human nature in the search to adjust to social environments—as in the case of kibbutzniks who believed it necessary that parents not care especially about their biological children. Contemporary social values may “necessitate” habituation to signals of social threat, but human beings may be prepared biologically for social anxiety and thus be not built to conform to these newly created necessities. Mismatches between social demands and the social anxiety that is part of the normal distribution of human nature should not be misrepresented by the psychiatric profession as mass individual disorder, any more than we should say that kibbutznik parents who wanted to know their biological children suffered from a disorder. Social arrangements are sometimes the culprit in human suffering, and psychiatry should not obscure this behind a veil of diagnostic labelling.
Campbell-Sills and Stein reply that DSM-defined social phobia is disorder nonetheless because changes in environmental conditions should be taken into account when judging dysfunction and disorder. They point out that asthma has increased because of air pollution and thus results from environmental changes. By analogy, they argue that social anxiety should be accorded disorder status even if it is attributable to changed social environments.
The cases, however, are not analogous, exactly as the harmful dysfunction analysis would predict. Pollution triggers a process resulting in genuine lung dysfunction that prevents the lungs from performing their designed function as judged by independent biological criteria; designed lung functioning does not become problematic. By contrast, in the cases of social anxiety at issue, the environment triggers no breakdown in designed functioning; rather, the way that human beings are naturally designed becomes a problem-in-living arising from changed social values and demands. The harmful dysfunction analysis classifies asthma resulting from pollutants as a disorder because the pollutants trigger a dysfunction; it classifies high temperamental social anxiety as a nondisorder because it is not a dysfunction but, rather, a conflict with social values or a frustrated personal desire.
Finally, Campbell-Sills and Stein offer the following practical reasons for classifying problems of social anxiety as disorders: to secure insurance reimbursement, to encourage research, and to encourage individuals to seek treatment. These are worthy goals, but they have nothing to do with the question of whether DSM-defined social phobia is generally a disorder. For example, both professionals and lay people distinguish the need for professional treatment from disorder status (3). Campbell-Sills and Stein also argue that social phobias as defined by the DSM-IV might perhaps be considered genuine clinical problems within the increasingly popular “health promotion” model, in contrast to the current “disease” model. By definition, however, health promotion goes beyond the treatment of disorder (and, incidentally, undermines the justification for reimbursement), so this argument implicitly acknowledges that DSM-defined social phobia is frequently a justifiably treatable nondisorder—our view, exactly.
Conclusion
Campbell-Sills and Stein offer no cogent objection to our arguments that most social phobia defined according to DSM-IV criteria is in fact socially disapproved normal variation rather than disorder (2). Asthma, their only proposed counterexample to the harmful dysfunction analysis, turns out to be a crystal clear, successful application of the analysis. Their arguments that DSM-defined social phobia is a disorder merge the very conditions—high-normal anxiety in contrast to dysfunction-based anxiety—that need to be distinguished and thus muddy the distinction between social control and medical intervention, potentially pathologizing many problems-in-living that no one considers disorders. Their practical arguments are important but separate from the present point of understanding whether DSM-defined social phobia is truly a disorder or a problematic normal variation.
Campbell-Sills and Stein acknowledge that some cases of DSM-defined social phobia are normal-temperament false positives. We believe that the above arguments show they greatly underestimate the problem by using inappropriate social-demand criteria for disorder. Whoever is right, our professional mandate and ethical commitments surely require that such false positives should be a matter of concern in drafting the DSM-V.
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