In Debate
Justifying the Diagnostic Status of Social Phobia: A Reply to Wakefield, Horwitz, and Schmitz
Laura Campbell-Sills, PhD1,
Murray B Stein, MD, MPH, FRCPC2
(Can J Psychiatry 2005;50:320–323)
Click here for author affiliations.
Are we overpathologizing the socially anxious? Wakefield, Horwitz, and Schmitz (1) explore this question and conclude the answer is “yes.” The authors base their judgment on a theoretical model in which disorders are “dysfunctions that cause harm” and dysfunctions are “failures of mental or physical mechanisms to perform biologically designed functions” (1, p 317). Wakefield and colleagues argue that no DSM-IV criterion for social phobia is a sufficient indicator of dysfunction. Consequently, many cases of social phobia are not disorders at all but, rather, instances in which individuals possess high levels of normal social anxiety.
Wakefield and colleagues offer a well-reasoned and stimulating critique of our current conceptualization of social phobia. We acknowledge that some cases of social phobia diagnosed in the community would be better understood as normal temperamental variants, rather than disorders per se. However, we also believe that most cases of social phobia that meet full DSM-IV criteria should qualify as disorders. In this article, we offer several responses to Wakefield and colleagues and advocate for the maintenance of DSM-IV social phobia’s status as a legitimate mental disorder. We divide our counterarguments into 3 groups: 1) questions regarding the viability of the harmful dysfunction model as a sole basis for defining mental disorders; 2) arguments in favour of DSM-IV social phobia’s qualifying as a harmful dysfunction; and 3) questions regarding the practicality of downgrading most cases of DSM-IV social phobia from disorder to some other label.
The Harmful Dysfunction Model May Not Provide Optimal Conceptualizations of Disorder
According to the harmful dysfunction model, the presence or absence of disorder hinges on the failure of mental or physical mechanisms to perform biologically designed functions. However, other definitions of disorder may be viable, or even preferable. We assert that exclusive use of the harmful dysfunction model denies disorder status to some conditions that experts would reasonably judge to be disorders. For example, it appears that the physical disorder of asthma would not qualify as a disorder in this framework. The human immune system is biologically designed to react to pathogens and irritants. In the case of asthma, the immune system is not failing to perform its biologically designed function—if anything, it is performing its function too well. Asthma involves an overreaction of the immune system that can be very uncomfortable and disabling. If not well managed, the condition can lead to severe respiratory complications and even death. Would we be comfortable with labelling asthma a normal variation of immune function rather than a disorder?
We assume that most readers would not support reclassifying asthma as an “extreme but normal variant” of immune function. However, it appears that mental disorders such as social phobia are more vulnerable to challenges to their validity than are physical disorders such as asthma. Perhaps this is because physical symptoms and complications from asthma are more observable and quantifiable than are the internal suffering and problems in psychosocial functioning associated with social phobia. When a person is short of breath, wheezing, and more prone to prolonged illnesses such as pneumonia, it seems logical to label the condition a disorder. However, when a person experiences extreme nervousness, negative thoughts, and impairment in academic, occupational, and interpersonal functioning, we are more willing to accept this as a normal variation in personality.
The stigma that has traditionally accompanied mental disorders may play a role in why we naturally view asthma and social phobia so differently. People who experience emotional difficulties and problems adjusting to academic, occupational, and interpersonal situations have not been offered the same level of concern from professionals or laypeople as have people with physical problems. When mental health problems are the focus, many of us still harbour views that individuals should “live with” or “get over” their problematic emotions. We should at least consider the possibility that the stigma associated with mental disorders plays a role in skepticism about social phobia’s status as a disorder.
A second problem with relying on the harmful dysfunction model of disorder (and its underpinnings in evolutionary biology) is that disorders are primarily defined in terms of how they affect the survival and well-being of the group or species. According to this definition, high levels of social anxiety in some percentage of the human population may not cause significant problems for the species and, instead, may be beneficial (for example, conflict may be reduced because not every member of a group is attempting to dominate). However, the evolutionary perspective does not permit us to consider the individual’s perspective and experience in defining disorder.
Although intense social anxiety may not affect the species negatively, it causes significant pain and problems in functioning for the individual sufferer. It is useful to accommodate the individual’s perspective in definitions of mental disorders, and not just for compassionate reasons. If we establish the presence of disorder based solely on the impact of symptoms on the group, we may artificially increase diagnosis rates of conditions for which the group has low tolerance (for example, attention-deficit hyperactivity disorder in classrooms). In contrast, we may fail to recognize other conditions because they disrupt individual lives much more than the larger social context (for example, childhood internalizing disorders). Defining disorder strictly from an evolutionary biology standpoint may overemphasize the group perspective to the exclusion of considerations pertinent to the individual.
Social Phobia Qualifies as a Harmful Dysfunction After All
Despite our reservations about the harmful dysfunction model, we believe that most cases of social phobia we encounter in clinical practice qualify as “harmful dysfunctions.” Wakefield and colleagues state that, for social phobia to constitute a disorder, “mechanisms that generate and regulate social anxiety [must] fail to perform their function of minimizing risk while allowing social interaction” (1, p 317). From their analysis of DSM-IV criteria, the authors conclude that this requirement for disorder is not met in most cases. We disagree and observe that, when mechanisms generating social anxiety are overactive, they do not minimize risk or allow for a normative range of social interaction.
Before explaining why we believe that mechanisms generating social anxiety fail to perform their function in social phobia, we wish to emphasize that we are considering the DSM-IV criteria in the aggregate. Wakefield and colleagues review each DSM-IV criterion for social phobia and conclude that none is a sufficient dysfunction indicator. We do not necessarily question the authors’ critiques of the individual DSM-IV criteria; however, we assert that, when considered as a set, the criteria do establish the presence of harmful dysfunction. In other words, an individual who experiences all the following very likely suffers from a harmful dysfunction: 1) marked and persistent fear of social situations, 2) consistent fear without habituation, 3) recognition that the fear is excessive, 4) avoidance of social situations or endurance of them with intense distress, and 5) significant interference with normal functioning or marked distress about the phobia.
We now return to the issue of whether the anxiety that characterizes social phobia according to DSM-IV criteria falls within the range of “minimizing risk yet allowing for social interaction.” With respect to minimizing risk, we argue that high levels of social anxiety may threaten the individual’s status within various relevant social groups. Patients with social phobia often report that others perceive them as rude or standoffish owing to their overly quiet demeanour. Moreover, they are frequently socially rejected because they hesitate to initiate or reciprocate social advances. They may not be integrated into social groups at school, work, or church. Consequently, because they have not built strong social connections, individuals with social phobia may be more vulnerable to certain threats to their well-being.
The presence of well-functioning social relationships appears to protect against negative health outcomes (2) and promote resilience to psychosocial stressors (3). It would therefore seem that high levels of social anxiety increase rather than decrease long-term risks to the individual. Persons with social phobia may also be more vulnerable to immediate dangers within social groups. In a confrontational situation, for example, it is conceivable that individuals with social phobia might be less likely to have supportive others to defend them because they have failed to establish the social bonds that underlie loyalty.
We further contend that the level of anxiety characteristic of individuals with social phobia does not allow the normative range of social interaction to occur. People with social phobia may have trouble building a social circle, may initiate dating very late or not at all, and may be unable to secure employment or higher education because they fear interviews and interacting with new people. These activities are integral to human life in the 21st century.
Wakefield and colleagues might counter that the demands of contemporary society are not relevant to establishing disorder status. Indeed, they state that “problematic mismatches between designed human nature and current social desirability are not disorders” (1, p 317). However, we argue that changes in environmental conditions over time are pertinent to judging whether a condition is a disorder or not. Wakefield and colleagues imply that only interactions with family and close familiars are species-expectable tasks for humans; therefore, discomfort and avoidance of social situations involving “casual” familiars and strangers is not considered disordered. However, the survival and flourishing of the human species has depended on the construction of increasingly elaborate social structures. Adequate functioning within these social structures requires interaction with casual acquaintances and unfamiliar people. In particular, it necessitates a habituation of the anxiety response once the organism has learned that a novel social situation is nonthreatening. In defining disorder, would we not wish to consider these present-day environmental factors?
We return to the example of asthma to illustrate why it may be important to consider physical and mental conditions in a sociotemporal context. Industrial societies produce more respiratory irritants than did preindustrial societies; partly as a result of this, asthma rates have increased dramatically (4). Would we refrain from labelling asthma a disorder simply because individuals with asthma could have been asymptomatic and nondisabled in a previous era? We presume that most medical professionals would take into account the interaction between the physiology of an asthma sufferer and current environmental conditions. The question then becomes, Why would we treat social phobia differently? Although intense anxiety in regard to acquaintances and strangers might not have impaired individuals in early human environments, it limits functioning substantially in our current social context. We believe that this interaction between temperament and current environmental conditions is relevant to defining social phobia as a mental disorder.
Pragmatic and Philosophical Considerations in Defining Disorder
Wakefield and colleagues acknowledge that most cases of social phobia merit treatment, even though they do not believe such cases qualify as disorders. The authors recognize that social phobia can cause suffering and argue that we must offer clinical attention “as a matter of justice and compassion” (1, p 319). However, diagnosis and intervention are highly intertwined in our current health care climate. Third-party payers fund treatment for disorders, not for unusually high levels of temperamental traits. From a practical standpoint, reclassifying social phobia as a normal variation of personality instead of a mental disorder would surely reduce access to treatment for this condition. Most problematic, individuals with high socioeconomic status might have access to treatment through self-pay options, while individuals with fewer financial resources would have to live with their discomfort and limitations. Moreover, anxiety disorders, including social phobia, are associated with social costs such as work disability (5) and increased incidence of comorbid conditions (for example, depression; 6). Unfortunately, these consequences of anxiety would be less likely to be examined and remedied if they were not associated with an identifiable disorder.
Finally, we must consider our vision for the medical community when establishing definitions of disorder. Western medicine has tended to adopt a disease model, where reduction or elimination of pathology is the solitary goal. The harmful dysfunction model of defining disorder fits neatly within this framework. However, support is gathering for health promotion models in medicine and related fields. In addition to ameliorating pathology, health promotion models focus on preventing pathology and helping individuals thrive (7). Within health promotion models, conditions such as social phobia, which impair individuals in their academic, occupational, and interpersonal roles, are perhaps more likely to be recognized as genuine clinical problems.
Promoting health and good functioning through health care has numerous social benefits. For instance, the public has benefited from high blood pressure’s classification as a disorder (even though it may be a normally distributed trait that does not constitute a harmful dysfunction). Medical professionals provide interventions for hypertension to avert more disabling outcomes, such as heart attacks or strokes. Because high blood pressure is considered a disorder, there is a strong drive to prevent it or to manage it effectively. What would be the ramifications of viewing high blood pressure as a normal physiological variation? Societal and professional attitudes would likely be affected, and possibly, more cases of hypertension would go untreated and lead to adverse outcomes. Similarly, societal and professional attitudes toward social phobia would change (with potential negative consequences) if its status as a genuine disorder were removed.
Summary
We believe that the harmful dysfunction model is important to consider when defining disorders. However, we question whether, when used in isolation, it provides an adequate basis for discriminating disorders from normal variations of temperament. We believe that it is important to consider the interaction between the individual’s temperament and the demands of present-day society. We also assert that, when taken in the aggregate, the DSM-IV criteria for social phobia adequately establish the presence of harmful dysfunctions, particularly when significant impairment in one or more important domains of functioning is present. Finally, we argue that practical issues must be considered when we classify conditions as disorders. The fact that social phobia is classified as a legitimate disorder has undoubtedly spurred research efforts and encouraged countless individuals to seek relief for their suffering.
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