Since May they have also had Paxil, the first drug approved by the Food and Drug Administration to treat social phobia or social anxiety disorder. Shy people also have a lot of company, according to the APA, which estimates that one American in eight--nearly 13 percent of the population--fears social situations. Social phobia now ranks as the third most common mental disorder, after depression and alcohol dependence.
'This isn't shyness or stage fright,' says Columbia University psychiatrist Jack Gorman in The Lancet (May 8, 1999). 'It's a fairly serious illness in which patients become so anxious in any performance situation that they can't handle it.'
Social phobics are plagued by the persistent fear that they will do something to embarrass themselves, say something stupid, or otherwise appear inept or inferior to others. They may be unable to attend parties, return things to a store, talk to members of the opposite sex, or speak up at business meetings. To avoid potentially embarrassing situations, they may resort to strategies so elaborate that normal day-to-day functioning is impaired. In the extreme, they may become shut-ins.
But some observers wonder whether the extent of the epidemic hasn't been slightly exaggerated. 'The notion that more than 35 million Americans are adrift on a sea of morbid shyness strains the limits of plausibility,' writes Michelle Cottle in The New Republic (Aug. 2, 1999).
Of course there are individuals who benefit from increased awareness of intense shyness. Cottle's concern is that the numbers have been artificially inflated by medical researchers, mental health practitioners, pharmaceutical companies, and advocacy groups, 'each operating from varying degrees of ambition, scientific knowledge, opportunism, and good intentions.'
Somewhere along the way, the boundaries blurred and we started seeing pathology where once we saw run-of-the-mill insecurity. Social phobia is 'this year's version of attention deficit disorder,' she contends. 'It's a 'hot' disease.'
It wasn't always that way, Cottle tells us. When social phobia entered the Diagnostic and Statistical Manual of Mental Disorders, or DSM-III (the American Psychiatric Association's periodically updated catalog of disorders) in 1980, it was considered 'relatively rare,' affecting some 2 to 3 percent of the population. The initial entry focused on the fear of only one activity--writing, eating, or public speaking, for instance--that compelled the individual to avoid the situation altogether.
By the early '90s, prevalence rates were pushing double digits, in large part due to a landmark journal article that appeared in the mid-'80s and caused the medical profession to take a second look at social phobia. Upon reassessment, the APA relaxed its definition to include a generalized subtype of the condition and removed the phrase 'a compelling desire to avoid' from the diagnostic criteria. At this point, 'marked distress' was enough to define social phobia.With each tweak of the diagnostic criteria, the numbers rose. The higher prevalence rates hinge on nothing more than a semantic shift. Drawing the line between common shyness and true pathology is now a matter of individuals' definitions of 'significant distress.'
As the numbers rose, so did the research dollars. Cottle notes that more than 20 projects are currently funded by the National Institutes of Health, up from a single study in 1986. Drug companies, eager to tap into a burgeoning market, also support research. They have even underwritten an Anxiety Disorders Association of America (ADAA) ad campaign: 'Imagine being allergic to people.'
Is this another example of 'the culture's crusade to medicalize any trait' that doesn't measure up to some ideal standard, as Cottle suggests? Will people be demanding Paxil to boost their confidence and interpersonal skills the way they already reach for Prozac to lift their spirits? (The two drugs are members of the same family.)
Psychiatrist Gorman hopes not. He cautions against asking for Paxil 'so I can be more outspoken at my next business meeting.' Pills, after all, aren't a cure. Symptoms return when patients stop taking drugs, notes Suzie Boss in American Health (July/Aug. 1999). Nor have there been any studies of the effectiveness or safety of long-term use of antidepressants for this disorder.
The best treatment is an individual plan combining psychotherapy, behavioral therapy, and drug therapy, writes H. Michael Zal in Consultant (April 1995). Zal, a clinical professor of psychiatry at Philadelphia College of Osteopathic Medicine and author of Panic Disorder: The Great Pretender (Insight Books, 1990), wants to increase clinicians' awareness of and ability to recognize patients with social phobia.
At the same time, he suggests that performance anxiety may be nothing more than an adaptive response. 'Where do shyness and the normal fear of ëperforming' in public end and social phobia begin?' he asks. 'It is often hard to tell. A low degree of anxiety may, in fact, enhance performance on stage, in a test situation, or in battle.'
If your life is circumscribed by shyness, it's good to know that help exists. But if you suffer only an occasional bout of the jitters, you might want to just learn to live with it--or find a recipe for those Powdermilk Biscuits.