AHP has previously discussed the socio-political side of changing the DSM, but a new book from Yale University Press adds an extra dimension to that coverage.

Shyness: How Normal Behavior Became a Sickness, by Northwestern English professor Christopher Lane, chronicles the “highly unscientific and often arbitrary way” in which widespread revisions were made to The Diagnostic and Statistical Manual of Mental Disorders (DSM).

“The number of mental disorders that children and adults in the general population might exhibit leaped from 180 in 1968 to more than 350 in 1994.”

Lane, who spent time in the archives of the American Psychiatric Association, uses social anxiety disorder (first dubbed social phobia) as the lens through which to analyze American psychiatry’s extraordinary shift in the last 30 years from a psychoanalytic orientation relying on talk therapy to its current emphasis on neuroscience and drugs.

He draws on letters and memos written by the framers of the new disorders to argue that DSM revisions to social phobia or social anxiety disorder placed the diagnostic bar too low, turning social anxiety into a mental illness common enough to be considered, according to recent studies, third only to alcoholism and major depression.

The DSM continues to stipulate that social anxiety disorder (SAD) must be “impairing” for a diagnosis to occur. The problem, Lane argues, is that DSM-defined symptoms of impairment in 1980 included fear of eating alone in restaurants, concern about hand trembling while writing checks, fear of public speaking and avoidance of public restrooms.

By 1987 the DSM had removed the key phrase “a compelling desire to avoid,” requiring instead only “marked distress,” and signs of that could include concern about saying the wrong thing.

“Impairment became something largely in the eye of the beholder, and anticipated embarrassment was enough to meet the diagnostic threshold….  That’s a ridiculous way to assess a serious mental disorder, with implications for the way we also view childhood traits and development, given the increased focus on reticence….  But that didn’t stop SAD from becoming what Psychology Today dubbed ‘the disorder of the 1990s.’”

In addition to providing extensive documentation from the American Psychiatric Association archives, Lane includes previously confidential material from the drug companies themselves that present a history of the antidepressant Paxil.

Social Anxiety bibliography.

• Fairbrother, N.  (2002).  The treatment of social phobia–100 years ago.  Behaviour Research and Therapy, 40(11), 1291-1304.

An important early work by the French psychiatrist, Paul Hartenberg, Les Timides et la Timidité, published in 1901, has been overlooked in the English language literature on Social Phobia. Hartenberg’s understanding of the phenomenology of social phobia is surprisingly similar to modem conceptualizations of the disorder. His description of the disorder corresponds very closely to the current DSM-IV criteria of social phobia. For example, he recognizes that socially anxious people feel anxious and ashamed in situations where there is no actual danger, and that these emotions occur only in the presence of others. Hartenberg clearly differentiates between social fears and other fears, noting that socially anxious people may be quite courageous in non-social situations. He also describes with considerable accuracy the typical symptoms of rapid onset anxiety. In a number of respects, Hartenberg approaches social phobia from a cognitive behavioral perspective, and describes an approach to treating social fears that is essentially graduated exposure to feared social situations. Hartenberg anticipated many advances in the area of social anxiety, and provided a number of insights that remain valuable.

• Gomperts, W.  (1993).  Sociale fobie en het sociaal fatsoen van gisteren. Over de tijdgebondenheid van psychische verschijnselen. / Social phobia and the social customs of the past: On the time dependence of psychological phonomena.  Psycholoog, 28(2), 45-52.

Discusses reasons for changes in psychological diagnoses over time. Two reasons are given for such changes: (1) methodological developments in psychology (2) and actual changes in psychological disorders. The hypothesis that the normal behavior of 1 era can become neurotic behavior in a later period is considered and assessed using psychological test results from the 1950s, which indicate that attitudes that were normal in that period are similar to what are currently considered social phobias.

• Himmelhoch, J., Levine, J., & Gershon, S.  (2001).  Historical overview of the relationship between anxiety disorders and affective disorders.  Depression and Anxiety, 14(2), 53-66.

Reviews the history of the relationship between “anxiety disorders” and depression, or affective disorders. First discussed is the linguistic derivation and evolution of the word “anxiety” and its related terms: in German, Angst, in French, both l’anxiété and l’angoisse, and in English “anxiety”, “fear”, and “anguish”. Second, the article describes the neuropsychiatric evolution of melancholia. Then, the authors describe the modern history of anxiety disorders including panic disorder, social phobia, obsessive compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. The final section of the article focuses on various nosological developments and shortcomings up to and including Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). It is noted that these positivistic nosologies have added difficulties to the distinctions between anxiety disorders and affective disorders.

• Lee,S.-H. & Oh, K. S.  (1999).  Offensive type of social phobia: Cross-cultural perspectives.  International Medical Journal, 6(4), 271-279.

Discusses different clinical features of social phobias across cultures. The article describes and gives an historical review of the offensive type of social phobia common in the East Asia, gives illustrations of non-offensive and offensive social phobia cases, explores sociocultural aspects of social phobia in East Asia, and describes treatment of social phobia for Koreans. While there are only a few cases of offensive type social phobia in the Western countries, a high proportion of social phobias reported in East Asia are of the offensive type. Ss with offensive type phobia are fearful of being with people based on the fear that certain of their body parts are offensive to others. Terminology and diagnostic and clinical features of taein kong po (fear of social relations) vs social phobia are explored. It is suggested that non-verbal social communication and a submissive social structure are related to a response style in social relations that favors offensive social phobia among East Asian people, particularly among Japanese and Korean Ss. Therefore, clinicians should be mindful when assessing or treating Asian patients that they may present with the offensive type of social phobia due to their cultural upbringing. Pharmacotherapy and group therapy are briefly discussed.

See also:

• Fei, Z. (2004). The Past and Present of Studies on Perfectionism. Psychological Science (China), 27(4), 943-945.

Perfectionism, an important diagnostic standard of DSM-III, is viewed as being associated with a variety of psychological problems. However, there has long been a lack of an accurate definition of perfectionism and quantitative studies. From 1980s on, in the fields of clinic psychology and gifted and creative education of Western countries, perfectionism has increasingly been regarded as a personality trait that is closely related to mental health and creativity and has multiple dimensions and aspects. The present article traces back to the origin of the studies on perfectionism, introduces the development and the present situation of this field.

-JTB.