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Editorial
Social Anxiety Disorder
Richard P Swinson
(PDF)

In Review
Psychological Treatments for Social Phobia
Karen Rowa, Martin M Antony
(PDF)

In Debate
Are We Overpathologizing the Socially Anxious? Social Phobia From a Harmful Dysfunction Perspective
Jerome C Wakefield, Allan V Horwitz, Mark F Schmitz
(PDF)

Justifying the Diagnostic Status of Social Phobia: A Reply to Wakefield, Horwitz, and Schmitz Laura Campbell-Sills, Murray B Stein
(PDF)

Social Disadvantage Is Not Mental Disorder: Response to Campbell-Sills and Stein
Jerome C Wakefield, Allan V Horwitz, Mark F Schmitz
(PDF)

Original Research Validation of a Revised Visual Analog Scale for Premenstrual Mood Symptoms: Results From Prospective and Retrospective Trials
Meir Steiner, David L Streiner, BaN Pham
(PDF)

Predictors of Professional and Personal Satisfaction With a Career in Psychiatry
Paul E Garfinkel, R Michael Bagby, Deborah R Schuller, Susan E Dickens, Fiona S Schulte, MA5
(PDF)

Are Dexamethasone Suppression Test Nonsuppression and Thyroid Dysfunction Related to a Family History of Dementia in Patients With Major Depression? An Exploratory Study
Konstantinos N Fountoulakis, Stergios G Kaprinis, Apostolos Iacovides, Konstantinos Phokas, George Kaprinis
(PDF)

Prevalence of Depression and Prescriptions for Antidepressants, Bella Coola Valley, 2001
Harvey V Thommasen, Earle Baggaley, Carol Thommasen, William Zhang
(PDF)

Suicide Ideation in Different Generations of Immigrants
M Alexis Kennedy, Karen K Parhar, Joti Samra, Boris Gorzalka
(PDF)

Brief Communication
Ropinirole in Treatment-Resistant Depression: A 16-Week Pilot Study
Paolo Cassano, Lorenzo Lattanzi, Maurizio Fava, Serena Navari, Giulia Battistini, Marianna Abelli, Giovanni B Cassano
(PDF)

Nightmares and Serum Cholesterol Level: A Preliminary Report
Mehmet Yucel Agargun, Mustafa Gulec, Ali Savas Cilli, Hayrettin Kara, Ramazan Sekeroglu, Haluk Dulger, Lutfullah Besiroglu, Rifat Inci
(PDF)

Book Reviews
(PDF)

Circles of Recovery: Self-Help Organizations for Addictions
Review by
Keith Humphreys

Group Psychotherapy for Psychological Trauma.
Review by
Paul Ian Steinberg

Roadblocks in Cognitive-Behavioral Therapy.
Review by
Irene Patelis-Siotis

Revenge of the Windigo. The Construction of the Mind and Mental Health of North American Aboriginal People.
Review by
Frank Frantisek Engelsmann

Letters to the Editor
(PDF)

Rabbit Syndrome Induced by Combined Lithium and Risperidone

Concomitance de troubles de la personnalité chez des hommes incarcérés

Case Reports as Letters Should Stay in The Canadian Journal of Psychiatry

Reply: Case Reports as Letters Should Stay in The Canadian Journal of Psychiatry

In Debate

Are We Overpathologizing the Socially Anxious? Social Phobia From a Harmful Dysfunction Perspective

Jerome C Wakefield, DSW, PhD¹ Allan V Horwitz, PhD² Mark F Schmitz, PhD³

(Can J Psychiatry 2004;49:736-742)

Click here for author affiliations. 

Some social phobias are clearly genuine mental disorders. However, in just 2 decades, social phobia (or social anxiety disorder) went from “rare” (in the DSM-III) to “common” (1), amidst changing criteria and concern about caseness thresholds (2). The evidence suggests that social anxiety is a normal, species-typical, designed response to specific triggering situations, one that is roughly normally distributed in temperamental intensity (3,4). This raises the question, Is temperamentally high but nondisordered social anxiety being mislabelled a disorder? We argue that many, perhaps most, people whom the DSM-IV potentially classifies as suffering from social phobia are probably not disordered.

Stein, a prolific writer on social phobia, asks the right question: “Are we needlessly ‘medicalising’ a normal variant of temperament, performing cosmetic psychopharmacology to remove blemishes of the personality?” (5). His answer: “No.” However, his reasons—that generalized social phobia is extreme on the social anxiety spectrum, undesired, and disabling in some social roles—also apply to many nondisordered features (for example, grief, homeliness, shortness, or selfishness). Moreover, roughly one-half of community diagnoses are nongeneralized cases. Further, neither biological differences between more and less anxious individuals nor findings that social anxiety runs in families show whether the more anxious are disordered or normal variants. Such correlates do not allow us to avoid the difficult conceptual question, When is social anxiety disordered?

The harmful dysfunction analysis of disorder (6–8), used here, holds that disorders are dysfunctions that cause harm, with dysfunctions defined as failures of mental or physical mechanisms to perform biologically designed functions. Problematic mismatches between designed human nature and current social desirability are not disorders; for example, such negative but biologically designed conditions as adulterous longings, taste for fat and sugar, and male aggressiveness are not in themselves disordered. Also, the extremes of normally distributed features are not necessarily disorders; it depends on whether they involve dysfunctions.

Judgments about normal and dysfunctional social anxiety remain at best plausible speculations. However, normal social anxiety is likely an adaptation preventing individuals from easily risking status in the group (9). In early environments, social groups were small and composed of familiars who cooperated but were nonetheless in competition for status and resources. Remaining an accepted group member despite such competition was critical to survival. A range of strategies balancing pursuit of status and avoidance of rejection—including some strategies involving high anxiety about placing oneself in social jeopardy and readiness for submission should jeopardy occur—likely had selective advantages. Moreover, normal social anxiety is exacerbated in our mass society, wherein we routinely negotiate new social hierarchies and, in some occupations, confront situations that tend to trigger anxiety by biological design. Our egalitarian society considers submissive displays that might reduce anxiety to be potentially embarrassing; consequently, they may be inhibited, further heightening anxiety. Substantial social anxiety under certain circumstances is thus compatible with normality.

What, then, distinguishes social phobia from normal social anxiety? Social anxiety is uncomfortable and thus involves harm. Whether it is disordered depends on whether a dysfunction exists; that is, whether mechanisms that generate and regulate social anxiety fail to perform their function of minimizing risk while allowing social interaction. Such dysfunction involves greatly disproportionate anxiety intensity relative to the triggering situation: anxiety reaches debilitating levels in species-expectable tasks or remains intense when biologically plausible triggers are absent or minimal, for example, during interaction with family members or other nonthreatening familiars; or when engaging in basic functions, such as eating away from home; or in situations where there is no real social scrutiny or chance of losing status, such as sitting anonymously in a lecture hall. Anxiety must not just occur in culturally desirable but species-unexpectable tasks, such as speaking before audiences.

Do DSM-IV criteria adequately distinguish dysfunctions from intense normal-range anxiety? Below, we assess DSM-IV criteria not by their various intended purposes, which they may accomplish, but by their validity as dysfunction indicators.

Criterion A requires “marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing” (10, p 416). This describes designed triggers of social anxiety (for example, scrutiny, humiliation, and strangers) that represented real threats during humans’ evolutionary shaping, but it does not distinguish normal from pathological responses. “Marked and persistent” anxiety about some situations can characterize normal individuals with a high-end socially anxious temperament. Perhaps marked and persistent fear of familiar people, without any real basis, that makes species-typical tasks such as interacting with family or other familiars uncomfortably difficult; or fear of social situations wherein scrutiny is absent, with anxiety dramatically disproportionate to threat of rejection, would indicate malfunctioning social anxiety responses.

According to Criterion B, “Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack” (10, p 417). However, almost invariable anxiety in feared situations characterizes both normal and pathological fears. Panic attack–level anxiety in routine social situations suggests dysfunction but is an example, not a requirement.

Intended to discriminate individuals with social phobia from individuals with psychosis, Criterion C nevertheless comes closest to addressing the existence of dysfunction: “The person recognizes that the fear is excessive or unreasonable” (10, p 417). Whether the person recognizes the fear as excessive or unreasonable may depend on social or personal values and is immaterial to disorder status; what matters is whether the fear is excessive or unreasonable. No baseline is specified for judging “excessive,” making that criterion either a value judgment (relative to social desirability) or circular (relative to nondisordered responses), unless it just redundantly means “unreasonable.” Consequently, the DSM’s critical claim is that social phobia is a disorder because it is “unreasonably” excessive relative to rational assessment of threat. However, unreasonableness is not an appropriate criterion for disorder. Evolution does not work according to reasonableness but according to what led to reproductive fitness. For example, it is unreasonable to fear snakes that you know are nonpoisonous. Nevertheless, when this biologically prepared fear is environmentally triggered, it seems to have no built-in distinction between a poisonous snake, which it is reasonable to fear, and a nonpoisonous snake, which it is not reasonable to fear: the fear seems designed to be of snakes, period. Unreasonable fear that enables escape from some rare catastrophic outcomes may serve reproductive fitness. In any event, what was reasonable when we were evolving social anxieties may not be reasonable in our current reduced-threat social environment, yet we are stuck with our normal human reactions.

Criterion D, “The feared social or performance situations are avoided or else are endured with intense anxiety or distress” (10, p 417), adds only that, if no anxiety occurs over time, then the feared situation is being avoided. Normally anxious people, however, avoid situations that make them uncomfortable. The criterion addresses harm, but specifying the type of situation, degree of disability, and trade-offs involved in avoidance would be essential to validly indicate dysfunction.

According to Criterion E, “Avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia” (10, p 417). However, social anxiety is designed to disrupt routine pursuit of social relationships when certain risks exist; such “clinical significance” criteria address harm but do not adequately distinguish dysfunctions from intense normal negative emotions (11). Moreover, evolutionary environments might not have designed us for certain activities, so only a subset of normal individuals may be well-suited to them. For example, some occupations in our culture require public speaking for efficient communication but that does not make natural fear of such activities a disorder, any more than the fact that few people are smart enough to be physicists, tall enough to be basketball players, or beautiful enough to be models makes the rest of us disordered. In short, social undesirability is being potentially mistaken for dysfunction. Distress about having social anxiety is irrelevant to disorder status, as is distress about other normal-range but socially limiting negative traits.

We conclude that lack of adequate dysfunction indicators combined with the normal distribution of social anxiety as designed negative emotion suggests that many or most people satisfying DSM social phobia criteria are temperamentally high in social anxiety but do not suffer from a disorder. They suffer from anxiety triggered by social situations we are designed to be wary of or from heightened anxiety caused by inhibiting the submission displays that would terminate the social threat. Their pathologization represents a classic confusion between social values and medical diagnosis. Thus epidemiologic prevalence estimates based on DSM criteria, which have driven the dramatically changing views of the magnitude of this problem, are questionable. Because clinical populations are largely self-selected, the magnitude of the false-positives problem in clinical settings remains unclear.

Nondisordered social anxiety can nonetheless cause enormous suffering. Such problems of living, resulting from mismatches between human nature and social expectations, deserve clinical attention as a matter of justice and compassion. Nevertheless, for many reasons ranging from homo- geneity of research samples to ethical informed consent, helping such individuals to lower their anxiety should not be confused with treating a disorder.