Biology 202
2002 Third Paper
On Serendip

As pharmaceutical companies began advertising on television several years ago, many prescription drug advertisements flooded the airwaves. One such drug was for the treatment of "social anxiety disorder," also called "social phobia." In investigating the causes, symptoms, and treatment of social anxiety disorder, I found that while drug companies and some researchers have hailed the unveiling of a drug for social anxiety as an important step, others feel that the disorder is poorly defined and its prevalence is exaggerated. Therefore, the following questions emerged: how did the diagnostic category of "social anxiety disorder" come about? How much of the disorder is rooted in cultural views of shyness? While certain individuals may indeed suffer from social phobia, it may be over-diagnosed because shyness is viewed as a condition in need of a cure.

This disorder consists of an intense fear of being watched by others or of being embarrassed in social situations. Such situations can include eating or writing in public, using public bathrooms, giving presentations and participating in a class discussion (1). Social phobia can also include fear of talking with strangers or "important people" and difficulty "being assertive" (2). Individuals may also experience physical symptoms such as sweating, shaking, and nausea. Additionally, before stressful situations individuals with social anxiety anticipate having these physical symptoms, often making them more severe. As a result, socially phobic individuals may avoid certain social situations, some to the point of missing school or work (1). Additionally, social phobia often co-occurs with other conditions, most often depression and alcoholism. An estimated one-half of all socially phobic patients have drug, alcohol, or other mental health problems: socially phobic individuals have a depression rate four times higher than average, and sixteen percent have alcoholism (2).

The disorder typically begins in childhood, and the National Institute of Mental Health estimates that 3.7 percent of 18 to 54 year olds in the United States have social anxiety disorder, with women diagnosed twice as often as men (1). Although researchers are not completely sure of the biological basis of social anxiety, some believe that its basis may lie in the amygdala, a small portion of the brain that controls fear response. NIMH scientists have also found a possible genetic component: through research on mice, they have found a gene that relates to fearfulness (1). Additionally, hormones may play a role, specifically fluctuations in estrogen and progesterone levels in women (4). Environment may also be important, as people with social anxiety may learn the behavior from watching and patterning those around them (1). Treatment may include the use of medications such as selective seretonin reuptake inhibitors (SSRIs), monamine oxidase inhibitors (MAOIs) and beta blockers specifically for "performance phobias." Individuals may also benefit from behavioral therapy, which involves gradual exposure to feared situations (1).

However, some believe that the category of "social phobia" or "social anxiety" is not so clear-cut. For example, the diagnosis of social anxiety can be difficult because of its co-occurrence with depression and other mental health conditions and the sometimes overlapping symptoms of these conditions (2). Another question that arises from reading literature on social anxiety is the difference between social anxiety and shyness. Researchers emphasize that social anxiety is a more extreme condition; however, some argue that the distinction is not always clear. Doctors diagnose social anxiety by asking patients questions about their anxiety levels in various social situations (7), which is of course a subjective measure that depends on the patients' perception of their anxiety.

Furthermore, some believe that the category of social anxiety came about because of changes in social perceptions of shyness and its resulting "medicalization." In her recent article in the Journal of Social History, historian Patricia McDaniel chronicles changing perceptions of shyness in the United States from the 1950s to the 1990s. McDaniel examined self-help books through the years, which were particularly targeted at white, middle-class consumers. She found that in the 1950s, shyness was viewed as a positive trait in women. In particular, women were advised to be shy in their interactions with potential husbands (3).

However, by the 1970s the women's movement had made shyness a less desirable trait: and excerpt from The Intelligent Woman's Guide to Dating stated that "tied tongue and locked legs were no longer attractive in a world where women commonly open up their needs and hearts to new acquaintances" (3). This change in advice books reflected general changes in societal attitudes about shyness. By the 1970s, shyness was seen as a problem in need of a "cure." For example, psychologist Philip Zimbardo stated in the late seventies that "shyness ... touches all of our lives in some way. What we each thought was our own secret hang-up is actually shared by an incredibly large number of people. And we can take great comfort in knowing we are not alone in our suffering." Additionally, the idea of shyness as rooted in biology gathered steam through the 1980s and 1990s (3).

As a result, some critics believe that the creation of the category of social anxiety disorder reflects that shyness moved from being a simple personality trait to a "syndrome" or "disorder" that needs to be cured. For example, from the 1970s to the 1990s an increasing number of Americans described themselves as shy (5), and the number diagnosed with social anxiety disorder rose as well. Additionally, social anxiety disorder first appeared as a diagnostic category in the American Psychiatric Association's Diagnostic and Statistical Manual in 1980 (5). While the original definition of social anxiety disorder included "avoidance of situations," later versions omitted this symptom and replaced it with "significant distress," amore general term which allowed more individuals to be diagnosed with the disorder (6). As a result, while in 1980 the percentage of American thought to have social anxiety was two to three percent (6), the percentage is now estimated as five to ten percent (4). Social anxiety is the third most common mental health problem after depression and alcoholism (6). Interestingly, while women are described as more likely to suffer from social anxiety disorder, men are more likely to seek treatment for the problem. The discrepancy may be because shyness is still considered more of a "feminine" trait that is looked upon more negatively in men (4) and therefore what might be considered "social anxiety" in men is considered "normal" in women.

Critics also believe that the recent rise is in part due to the aggressive marketing efforts of drug companies such as SmithKline Beecham, which in 1999 began marketing its antidepressant Paxil as a treatment for social phobia. The television and print ads for Paxil gave gloomy portraits of those suffering from social anxiety and framed it as a "pathology." Additionally, the media has devoted increasing attention to the disorder, including testimonials from celebrities who claim to suffer from the disorder (5). Social phobia researchers and advocates may have also overestimated the prevalence of the disorder in order to garner more attention and funding. As a result, social phobia became a "hot disease" like attention deficit disorder, which has also had a huge increase in prevalence in recent years (6).

While such critics acknowledge that certain individuals may indeed suffer from crippling social anxiety, the increasing publicity on social anxiety disorder may lead certain individuals to seek treatment who may be shy but not necessarily have a disorder. For example, the Paxil website states that "some people find comfort just by learning social anxiety is a medical condition (emphasis added) and that medication can put you "in control of your anxiety"(7). The website implies that the construction of social anxiety disorder as a medical category with an accompanying drug treatment legitimates it as a "real" problem. While some individuals may take comfort in the idea of social anxiety as a medical condition, critics believe that the sharp rise in individuals seeking treatment for social anxiety reflects the medicalization of a personality trait (6). Also, researchers point out that a certain level of anxiety or nervousness is normal, and an edge of anxiety before a major event may actually be beneficial (6).

As stated earlier social anxiety disorder has a broad definition (6) and the diagnosis is subjective, consisting of a patient rating their anxiety in social situations (5). Additionally, its relationship to depression and alcoholism needs to be further explored, since its symptoms may overlap with symptoms of these conditions. It appears that certain biological factors such as the amygdala and hormone fluctuations may contribute to social anxiety (1), but further research in these areas is necessary

Also, how to "draw the line" between shyness and social anxiety is a question that needs to be addressed further (5). Whether shyness is considered a "trait" or a "disorder" depends on the intensity of symptoms (1). I do not want to minimize the suffering of individuals with social anxiety. Some people indeed suffer from social anxiety disorder and need medication and therapy. However, others may simply be seeking medical assistance for a personality trait that may not need correcting. The rise in the diagnosis of social anxiety disorder may in part be because of increasing awareness of the disorder, but also reflects a society that frowns on shyness. As a writer recently asked in The New York Times Magazine, "Is somebody out there inventing the drug to treat excessive perkiness?" (5).

WWW Sources
1) "Facts about Social Phobia", from the National Institute of Mental Health

2) "Social Anxiety Disorder: A Common, Unrecognized Mental Disorder", on the American Academy of Family Physicians site.

3)"McDaniel, Patricia "Shrinking Violets and Caspar Milquetoasts: Shyness and Heterosexuality from the Roles of the Fifties to the Rules of the Nineties", Journal of Social History, Spring 2001, v34:3 (Available online on Gale Group)

4) "Social Phobia- Not Just Another Name for Shyness", on the JAMA website.

5) "The Shyness Syndrome", a reprinted version of a recent New York Times Magazine article

6) "Is Shyness Catching? Docs are on a hot new disease: social phobia", from the "Utne Reader Online"

7) Social Anxiety Disorder site, by Paxil.


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