When Does Benign Shyness Become Social Anxiety, a Treatable Disorder: The Authors Pinpoint the Fine Line between Overdiagnosis and Underdiagnosis of SAD

Since the appearance of social anxiety disorder (SAD) in the DSM-III in 1980, research on its prevalence, characteristics, and treatment have grown (Box 1, page 22 (1), (2)). In addition to the name, the definition of SAD has changed over the years; as a result, its prevalence has increased in recent cohort studies. This has led to debate over whether the experience of shyness is being over-pathologized, or whether SAD has been underdiagnosed in earlier decades. Those who argue that shyness is being over-pathologized note that it is a normal human experience that has evolutionary functions (eg, preventing engagement in harmful social relationships (3)). Others argue that a high degree of shyness is not beneficial in terms of evolution because it causes the individual to be shunned, so to speak, by society. (4) [ILLUSTRATION OMITTED] Box 1 What's in a name? The name of social anxiety disorder (SAD) has changed over the years in the DSM. First referred to as social phobia in the DSM-III, it later was given the alternative name of social anxiety disorder in DSM-IV. Most recently, it has been fully changed to social anxiety disorder (social phobia) in DSM-5, based on the belief that "social phobia" does not reflect the impairing and pervasive nature of the disorder. (1) The generalized specifier was removed in DSM-5, perhaps because the name change is more reflective of this more severe subtype. and the specifier "performance only" was added, based on recent research suggesting that persons with performance-only fears significantly differ from those with multiple fears (see Bagels and colleagues' review of this topic (2)). The performance-only form of SAD is significantly less prevalent than the generalized form, and tends to be treated with as-needed medication (eg, a beta blocker) that can be taken before entering a performance situation. Why worry about 'over-pathologizing'? The medicalization of shyness might be a reflection of Western societal values of assertiveness and gregariousness; other societies that value modesty and reticence do not over-pathologize shyness. (5) It is important not to assume that someone who is shy necessarily has a "pathologic" level of social anxiety, especially because some people who are shy view that condition as a positive quality, much like sensitivity and conscientiousness. (5) The broader issue of what constitutes a mental disorder arises in this debate. A "disorder" is a socially constructed label that describes a set of symptoms occurring together and its associated behaviors, not a real entity with etiological homogeneity. (6) Labeling emotional problems "disordered" assumes that happiness is the natural homeostatic state, and distressing emotional states are abnormal and need to be changed. (7) A diagnostic label can help improve communication and understand maladaptive behaviors; if that label is reified, however, it can lead to assumptions that the etiology, course, and treatment response are known. Proponents of the diagnostic psychiatric nomenclature have acknowledged the dangers of over-pathologizing normal experiences of living (such as fear) by way of diagnostic labeling. (8) [ILLUSTRATION OMITTED] Determining when shyness becomes a clinically significant problem--what we call SAD here--demands a delicate distinction that has important implications for treatment. On one hand, if shyness is over-pathologized, persons who neither desire nor need treatment might be subjected to unnecessary and costly intervention. On the other hand, if SAD is underdiagnosed, some persons will not receive treatment that might be beneficial to them. In this article, we review the similarities and differences between shyness and SAD, and provide recommendations for determining when shyness becomes a more clinically significant problem. We also highlight the importance of this distinction as it pertains to management, and provide suggestions for treatment approaches. …