Blushing, Once a Virtue, Now a Symptom

By Christopher Lane
Yale University Press, 263 pages, $27.50

Every student of medical history knows that the psychiatric establishment is not immune to fads and fallacies. A Victorian physician once estimated that a quarter of all women suffer from “hysteria”—a vague, catchall diagnosis modern psychiatrists have banished from clinical circles. Remember learning about “multiple personality disorder” from Primal Fear and Fight Club? That’s probably a canard, too. In his excellent new book, Shyness, Christopher Lane identifies another dubious mental illness. Perhaps you’ve read about it on highway billboards: It’s called social anxiety disorder.

Mr. Lane traces the discovery—or rather the creation—of social anxiety disorder to the late 1970’s, when the American Psychiatric Association updated its Diagnostic and Statistical Manual of Mental Disorders. A small group of leading psychiatrists deleted a few entries, tweaked others, and added dozens of new mental illnesses. The science behind these sweeping revisions was shockingly flimsy. Mr. Lane reveals that the task force members conducted little systematic research, and often based their conclusions on ambiguous studies.

Case in point: The decision to include “social phobia” (later rebaptized social anxiety disorder) rested almost entirely on a 1966 review sketching “several different kinds of panic” by psychiatrists Isaac Marks and Michael Gelder. The review stated that a small number of patients became anxious when required to participate in social situations. These patients feared “blushing in public” and “going to dances.” If these symptoms seem ill-defined and prosaic to you, then you’re on to something: Messrs. Marks and Gelder said themselves there was no evidence that social phobics form a coherent group.

Worse yet, the task force set the bar for the newly discovered ailment dismayingly low. The current D.S.M. definition of social anxiety disorder reads, in part: “a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.” For Mr. Lane, that sounds suspiciously close to plain old shyness. He argues convincingly that the cavalier D.S.M. task force effectively pathologized normal behavior.

He’s somewhat less convincing when he attacks psychopharmacology. According to Mr. Lane, the A.P.A.’s official recognition of social anxiety disorder resulted in a windfall for pharmaceutical companies. That’s true—think Paxil and Zoloft. It’s also true that due to low diagnostic thresholds, psychiatrists occasionally prescribe drugs for mild ailments. But Mr. Lane seems to me excessively nostalgic for the pre-drug, talking-cure days. He gives short shrift to the fact that some people suffer from acute anxiety problems, and glosses over the many studies proving that medication, especially when combined with therapy, really can improve some patients’ quality of life.

Nevertheless, Shyness is a welcome contribution to psychiatric discourse. According to the National Institute of Mental Health, social anxiety disorder affects about 15 million American adults—a strong indication that Mr. Lane is right: The D.S.M.’s nomenclature is indeed far too expansive.

If you don’t believe it, try taking the social phobia self-test on the Facts for Health Web site ( I did—and I was encouraged to talk with a health care professional about my symptoms.


Juliet Lapidos is an editorial assistant at Slate. Blushing, Once a Virtue, Now a Symptom