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Are Diagnoses Too Inclusive?

Christopher Lane has an excellent article in yesterday’s The Boston Globe about the murky line between normal shyness and something called social anxiety disorder (also known as social phobia). The article examines the difficulty in telling “normal behavior” from something that’s diagnosable as a mental disorder, and rightfully picks on this disorder as a prime example of the blurred line. But first Lane drives a dagger into what passes for science on social anxiety disorder:

The Society of Nuclear Medicine has been touting a new study that suggests we’re one step closer to solving the riddle of social anxiety disorder. Researchers believe the origins of the disorder are biological. […]

Once you start calling fear of criticism a psychiatric disorder, it’s easy to ignore the countless social and psychological factors that cause stress and anxiety. Yet the justification for calling the disorder biological turned out to be modest at best. MRI scans of five women and seven men who met the criteria for social anxiety disorder suggested that minor fluctuations of dopamine and serotonin “may play a role in the neurobiology of social anxiety disorder.”

That’s a bit like saying, “Exercise will increase your heart rate” or “Caffeine is a stimulant.” Microscopic fluctuations of dopamine and serotonin impact the brain all the time, helping determine our moods. It’s a stretch to predict the health of 15 million Americans from a brief focus on only a dozen of them.

Indeed. Researchers get excited when they seem some correlation within their data, but then almost universally over-extend and generalize the meaning of that correlation and data.

Much of these types of studies that purport to find some sort of brain chemical link for a specific disorder have amounted to very little in changing the way most disorders are diagnosed and treated.

But the larger point Lane makes in the article is about the fuzzy lines between the diagnostic criteria for many mental disorders, and what most of us would consider normal behavior. He picks on social anxiety disorder, and rightfully so, because it is one of the most useless diagnoses in the entire diagnostic manual.

What he glosses over, though, is that for a person to meet the diagnosis of social anxiety disorder, he or she must meet a total of 8 different criteria. Some criteria he doesn’t mention in his article are things like:

  • The person recognizes that the fear is excessive or unreasonable.
  • The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
  • The 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.
  • In individuals under age 18 years, the duration is at least 6 months (so much for the senior prom example in the article).

I highlighted some of the words. These are the words trained mental health professionals look for when diagnosing someone with this particular disorder. If you’re just experiencing a few butterflies in your stomach before making an annual presentation to your boss, that’s not social anxiety disorder.

I agree with Lane’s overall theme that perhaps professionals (and especially health professionals like family physicians with little specific mental health training) are over-diagnosing many mental disorders these days due to inexact diagnostic criteria. But I also believe overdiagnosis is also happening because of a simple lack of adherence to the criteria that do exist.

Shyness, as Lane reminds us, is not a mental disorder, and social anxiety disorder is not the same as being shy or having a personality that favors shyness. Shyness is just a normal, everyday trait that some people have — and it’s perfectly okay.

But the problem of overdiagnosis, like Lane believes, is a real one and must be addressed:

To restore public and professional confidence in the manual, the organization needs to raise, not lower, its diagnostic thresholds and delete every reference in the manual to mild or routine suffering, so that it’s possible once more to distinguish between the chronically ill and the worried well.

I concur. We must do a better job with the validity of this diagnostic system in its next revision, and seek to continually improve upon our abilities to reliably diagnose these disorders. Because suggesting someone is “ill” and in need of treatment when they are perfectly healthy helps no one.

Read the full article: Shyness or social anxiety?

Are Diagnoses Too Inclusive?


John M. Grohol, Psy.D.

Dr. John Grohol is the founder and Editor-in-Chief of Psych Central. He is a psychologist, author, researcher, and expert in mental health online, and has been writing about online behavior, mental health and psychology issues since 1995. Dr. Grohol has a Master's degree and doctorate in clinical psychology from Nova Southeastern University. Dr. Grohol sits on the editorial board of the journal Computers in Human Behavior and is a founding board member of the Society for Participatory Medicine. You can learn more about Dr. John Grohol here.


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APA Reference
Grohol, J. (2018). Are Diagnoses Too Inclusive?. Psych Central. Retrieved on August 23, 2019, from https://psychcentral.com/blog/are-diagnoses-too-inclusive/
Scientifically Reviewed
Last updated: 8 Jul 2018
Last reviewed: By a member of our scientific advisory board on 8 Jul 2018
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