When ‘social phobia’ first entered the American Psychiatric
Association’s (APA) lexicon of mental disorders in 1980, shy people
had little to fall back on, except perhaps Garrison Keillor’s
preferred remedy, Powdermilk Biscuits.
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.
