Are we overpathologizing the socially anxious? Social phobia from a harmful dysfunction perspective.

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 strategics 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. …