You always hated it when the teacher called on you in class. Even now, you get those big, fluttering “butterflies” in your stomach before making a speech. You stay away from parties because you feel a little self-conscious around people. Your mom always described you as “shy” and you admit you’re a bit of a “wallflower”. So do you qualify as having a diagnosable mental disorder? Unless there’s much more to your story, the answer is no.
But now consider Gina, a patient described by psychologists Barbara and Gregory Markway, in their book, Painfully Shy. In school, Gina not only dreaded being called on by the teacher, she would also “freeze up” and literally be unable to speak — a condition termed “selective mutism.”
Now, in her adult years, Gina never dates and is so anxious about how her co-workers will judge her, she won’t eat lunch with them. Gina tells Dr. Markway that, “I feel like I’m always under the spotlight, as if people are evaluating every word I say, every move I make. Sometimes I feel paralyzed by it. I just know I’m going to do or say something to make other disapprove of me.” She adds, tearfully, “I feel like there’s something terribly wrong… the way I am is not normal.”
Does Gina have a psychiatric disorder? Probably so, and it goes by the name of Social Anxiety Disorder (SAD). Some clinicians refer to this as “Social Phobia,” but others reject this term. They point out that the generalized form of SAD often pervades the sufferer’s life in ways that so-called simple phobias, such as an intense fear of spiders, do not.
A recent national survey known as the NESARC (1) assessed more than 43,000 adults in the U.S. and found that 5% suffered from SAD at some period in their lives. This would make SAD one of the most common psychiatric disorders, with a higher lifetime prevalence than bipolar disorder. SAD usually begins between 11 and 19 years of age, and affects slightly more females than males. Some evidence indicates that SAD may run in families. In my own practice, I found that many patients with intense social anxiety also had problems with depression, substance abuse, or both. This was confirmed in the NESARC study: nearly half of those with SAD also suffered from an alcohol use disorder; and more than half, from a mood disorder. The NESARC study also found that SAD usually ran a chronic course with marked impairment in social and vocational function.
Yet SAD remains controversial, both outside and within the mental health profession. Writing in the Sept. 21, 2007, New York Times, English professor Christopher Lane found it “baffling” that “…ordinary shyness could assume the dimension of a mental disease…if a youngster is reserved, the odds are high that a psychiatrist will diagnose social anxiety disorder and recommend treatment.”
Well, not really — not if the psychiatrist is well-trained and has a lick of common sense. What pushes a condition into the realm of illness is marked and persistent suffering and incapacity. Indeed, the current diagnostic criteria for SAD (in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition) require the presence of “marked and persistent fear” of social or performance situations; avoidance of these situations; and the person’s recognition that the fear is “excessive or unreasonable”. In those under age 18, symptoms must be present for at least six months. Most critically, the social anxiety “interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities.” DSM-IV is not talking “butterflies” in the stomach!
Yet even some mental health professionals have raised questions about SAD. Writing in the April 13, 2002 British Medical Journal, psychiatrist Dr. Duncan Double argues that, “…although definitions of the syndromes of shyness and social phobia may differ, the distinction is difficult to make…Furthermore, we should be skeptical about the potency and benefits of drugs for this condition.” Even psychiatrist Dr. Bruce Black, one of the most prominent early researchers of SAD, wrote me to say that, “Everybody has some social anxiety…So even though I see individuals of all ages with severe impairment, I can understand some of the criticism of social anxiety as a categorical disorder.”
Similarly, as psychologist Dr. John Grohol recently wrote me, “Social anxiety disorder is a real disorder in a small set of the population. …On the other hand, because there are some medications now available for this disorder, I believe it is being over-diagnosed and that doctors do not rigorously [or] reliably apply the diagnostic criteria we do have.”
Perhaps so, in clinical settings where a thorough evaluation isn’t performed. Yet the NESARC study found that over 80% of SAD sufferers received no treatment, and that the number of treated cases hasn’t changed in the last 20 years. This hardly supports the notion that “Big Pharma” has steam-rolled doctors into over-diagnosing and over-medicating SAD. Furthermore, we have good evidence from countries as diverse as Australia, Brazil, China, and Japan that SAD is “real”, common, debilitating, and often under-treated.
In the U.S., the NESARC study found a one-year SAD prevalence of 2.8%. An Australian study by Lampe and colleagues (2) found a similar yearly SAD prevalence of 2.3% in Australia—despite the comparatively limited “marketing” influence of the Australian pharmaceutical industry. In Brazil, Rocha and colleagues (3) found one-year SAD prevalence rates of 5-9%, depending on the diagnostic criteria. And in the first such study of Chinese patients by Dr. Sing Lee and colleagues, the one-year prevalence of SAD was 3.2% — similar to that in the U.S. These multi-cultural data simply don’t support the notion that American psychiatrists are pulling this diagnosis out of thin air.
To be sure: clinicians must adhere to strict criteria for SAD, so that everyday “shyness” is not pulled into the net of psychopathology. We must also continue our search for the genetic, biochemical, and psychosocial factors that lead to SAD. But first, we need to take care of those, like Gina, who suffer greatly with this condition.
The writer is Professor of Psychiatry, SUNY Upstate Medical Center, Syracuse, N.Y.; and Clinical Professor of Psychiatry at Tufts University School of Medicine in Boston. His most recent book is, Everything Has Two Handles: The Stoic’s Guide to the Art of Living. (Hamilton Books).
1. National Epidemiologic Survey on Alcohol and Related Conditions, reported by Dr. Bridget Grant and colleagues in the November 2005, Journal of Clinical Psychiatry.
2. Reported in the May 2003 issue of Psychological Medicine
3. Writing in Rev Bras Psiquiatr. 2005 Sep;27(3):222-4. Epub 2005 Oct 4.)