What if social anxiety isn’t a disorder?

The BBC news website has a big article about social anxiety disorder, with specific reference to Christmas. It’s illustrated, of course, with one of those unintentionally hilarious photos that features editors love so much: a woman in a beige jacket and slightly unkempt hair, with one hand to her face, and an out-of-focus Christmas tree looming over her like a giant, sparkly triffid. The article itself is one of those generic ones that get cranked out at Christmas time. Alongside the ‘Weather Spells Xmas Chaos’ article, and the ‘Council Scrooges Ban Christmas’ article, this is the obligatory ‘Unhappy Xmas’ article. It is, despite this, perfectly ok.

It provides a brief description of social anxiety, some first-hand testimony from people affected, some limited discussion of treatment options, and links prominently to sources of further information and advice – I was especially pleased to see the link to the online self-help community, SAUK. I’m not sure it was wise of the author to venture for all of five sentences into the middle of the Great Psychotherapy Versus CBT Wars, and there’s a really odd stab at “balancing” the article by introducing someone called Alex just so it can be reported that s/he likes Christmas. (I’m really not sure why even the most scrupulously impartial of journalists, one who’d swallowed a whole shelfful of BBC Compliance manuals, would think that an article saying some people find Christmas unpleasant requires specific balancing like this.) But, taken as a whole, it is perfectly ok.

So much for the article per se; I don’t want to write about it directly. I want to write, instead, about a larger question: what if social anxiety isn’t a disorder?

No-one can dispute, of course, that there are people who find social situations unpleasant. No-one can dispute that this exists on a spectrum, with pretty much everyone feeling at least mild nervousness at the prospect of being the only stranger among a group of people who already know each other (that first day at work feeling), and others wholly incapacitated in any situation which has even the slightest ‘social’ connotation. No-one can dispute that some people find their inability to cope in social situations a source of both stress and distress, and that these people may benefit from talking treatments aimed at helping them to manage and understand their anxiety, and their reactions to it, better. I don’t have any beef with people who seek out this kind of help, or people who provide it to them – seeking alleviation of your distress is always sensible, and trying to alleviate the suffering of others is both worthwhile and kind.

But the question remains: what if social anxiety isn’t a disorder? What if (to recycle the suspiciously round-number statistic quoted by the BBC) the 10% of people in the UK who experience social anxiety aren’t suffering from a disorder, but are just people who don’t enjoy social situations? What if there’s nothing disordered about preferring a quiet night in with the telly to standing in the corner at the Christmas party hoping that Becca, who’s doing that thing with the photocopier, wiped really thoroughly last time she used the ladies? What if there’s nothing disordered in preferring a peaceful and solitary Christmas afternoon with a big glass of wine and a good book to spending time with “overtired” little Jimmy, or uncle Bert and cousin Elspeth who are still Not Talking because of who cheated who at Trivial Pursuit in 2007? What if it’s just a matter of legitimate personal preference instead?

The basic problem, as I see it, is that we structure our society in such a way that participating in non-essential social rituals is made to seem mandatory. That problem’s then compounded by the way participation is insisted upon: not by directly ordering people to attend, but by telling them they should want to attend because they’ll have fun, and what kind of person doesn’t want to have fun? In this way, people begin to be persuaded that, if they don’t enjoy social situations, they are in some way defective – that their inability to take pleasure in social situations doesn’t indicate that they prefer different pleasures, but that they have a “personal problem” that they need to “fix”.

That’s how you end up with miserable people at parties, and drinking too much in the hope that emotional disinhibition will look enough like pleasure to pass muster. That’s how you end up with people who prefer their own company dragging themselves through joyless social events so that they can win the “prize” for doing so effectively – being invited to yet more social events that they will also feel compelled to attend, and which they will also fail to enjoy. That’s how you end up with people ruminating obsessively over their own “failures”, worrying back-and-forth, back-and-forth over their own recalcitrant feelings, which stubbornly tell them: hey, you’re really not enjoying this. That’s how you end up with people coming to believe that their own feelings, because they’re the opposite of what they’re “supposed” to be, are “disordered”.

It’s into the middle of this that kind, well-meaning mental health professionals stride, and set about trying to do good. They describe and characterise the problem – and by doing that confirm it as a quasi-medical problem that both can and should be “cured”. They identify people’s spontaneously-arising feelings of discomfort as symptoms of disease, that must either be “managed” or “analysed”, not as evidence of a naturally occurring variation within the population. They persuade “sufferers” of this “disease” that, if they’re uncomfortable in social situations, the rational course of action is to seek to mask or evade their feelings of discomfort, rather than to pay attention to what their feelings of discomfort are actually telling them: that social situations are not for them.

The problem here, at its heart, is that mental health professionals have no stable definition of what it is they seek for their patients. They have no clear idea – and certainly no coherent articulation – of what the state of perfect healthiness and equilibrium to which they are trying to guide their patients actually is. There are no empirical measurements to which they can appeal (as there are for their physician counterparts who treat physical ailments), which leaves them looking elsewhere for their definitions of healthy/unhealthy or functional/dysfunctional. And there is only one place where they can look: to comparisons of the individual in front of them with what is usual, or typical.

Oftentimes this works as a quick-and-dirty heuristic, if nothing else. It may not be possible to say precisely how someone who is experiencing a pattern of paranoid delusions is unwell, but a comparison of their perceptions and preoccupations with those of everyone else is an effective means of demonstrating that they are unwell. The problem is that this process of compare-and-contrast can also be the means by which the separate concepts of healthy/unhealthy and typical/atypical are elided, so that they come to mean the same thing.

This is why, for example, a member of the Roman Catholic priesthood is considered perfectly healthy (which is to say typical) if he believes God has granted him the power to turn bread and wine into flesh and blood, but an ordinary member of the public is considered unhealthy (which is to say atypical) if she believes that God has granted her the power to communicate with angels. On the face of it, neither of these ideas is any more or any less outlandish than the other, and there is no intellectually coherent – and certainly no empirical – basis on which to defend the distinction between them. But is is possible to demonstrate that one is typical and the other atypical, and this is the means by which the conclusion is reached that one is healthy, and the other unhealthy.

Unfortunately, this elision of the difference between unhealthy and atypical can lead into dark territory indeed, where harmless differences between people are seen as sinister deviations from “normality” that must be corrected. This is something of which I’m unavoidably aware as a gay man. I can’t forget that homosexuality – many decades ago now, to be sure – was once classed as a mental disorder. The reason for this is that it was considered, not as a simple variation within the population, but as a deviation from heterosexuality that had to be “cured”. People’s spontaneous feelings of romantic and sexual attraction towards their own sex were identified as “problems” that needed to be “fixed”.

That was all a long time ago, of course. These days the mental health professions have come so far on questions of sexual orientation that members of their own ranks who argue that homosexuality is a “problem” that ought to be “fixed” can be struck off. There is universal agreement, nowadays, that if a counsellor, psychologist or psychiatrist is approached by a client who is experiencing distress as a result of their homosexual feelings, the only ethical action for that professional is to pursue a course of treatment aimed at helping their client to come to terms with their feelings. I would like to suggest that something similar may be appropriate when it comes to social anxiety.

What if – instead of being put through a programme to minimise or manage their feelings of distress in social situations – socially anxious people were instead given help to come to terms with their feelings? What if therapists were to see it as their mission to help their clients understand that, yes, there may be a strong social expectation of sociability (just as there is a strong social expectation of heterosexuality), and, yes, our culture may continuously reinforce the idea that everyone “ought” to find their happiness in social gregariousness (just as the idea that everyone “ought” to find their happiness in heterosexual romance is continuously reinforced) – but that just reflects what’s typical for the majority, not what’s mandatory for everyone?

What if MH professionals were to encourage their socially anxious clients to adapt the life they lead in light of their feelings, and not to try and force their feelings to adapt to the life they’re told they must lead? What if they were to stand with individuals and say “society needs to accommodate people who feel this way”, instead of standing with society and saying to individuals “you need to change to accommodate social expectations”?

There really is a lot of pressure around the idea that sociability is a requirement for us all. Back when I started this blog, there’s no way I’d have posted something on Friday night (especially not the Friday before Christmas), even if I wrote it then. I’d have scheduled it to appear automatically on Saturday afternoon, so strong would have been the compulsion I felt not to admit to spending my evenings quietly footling in front of the computer.

Well, enough of that. I’m on my own tonight, the Friday before Christmas, and perfectly happy that way – a contrast to the discomfort and anxiety I’d feel if I was at a house party or a club, and trying to fake happy. I’ll be alone by choice on Christmas day for the fourth time this year, and will be quietly content – so much more content than I would be trying to navigate the social currents at my sister’s house (the place I’d have ended up if I’d capitulated to social pressure). On Hogmanay I’ll be – you guessed it! – alone and doing my own thing. I’ll turn on the TV long enough to hear the bells and see the fireworks, then turn it off again without obeying the All People Must Now Enjoy Themselves ultimatum.

My distaste for social situations doesn’t mean that I dislike all company in all situations. I enjoy meeting up with people in ones and twos for a chat and a laugh (or at least I do when my assorted mentalisms make it possible, which is too rarely). It’s just the awful, let’s-all-join-in, happiness-is-mandatory, cheer-up-it-might-never-happen group socialising that I don’t enjoy. And, because I don’t enjoy it, I avoid it. I do other things with my time instead – things that I enjoy, even if party-hearty totalitarians might think they’re lame, or sad.

And – you know what? – the same thing might be true for you. It’s something to consider as a possibility, at least, before you go down the quasi-medical route. What if, instead of making yourself endlessly miserable in the pursuit of a pleasure that you are not temperamentally suited to, you just gave up on it? What if you spent your leisure time doing things you actually enjoy, instead of the things other people think you “ought” to enjoy?

Clearly, if anxiety of any kind is preventing you from doing things you need to do – going to work or college, finding a job, etc – then that’s a different situation, and a solution has to be found. But if the anxiety is only caused by things you don’t need to do – going for a coffee before a lecture; hitting the pub after work – then you could at least consider the possibility of not doing them. It is allowed, after all, it is permissible. It’s an option you can consider as an alternative to therapy, if you want to.

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5 Responses to What if social anxiety isn’t a disorder?

  1. Hallo Aethelread, Happy Christmas!

    I haven’t read the BBC article, so maybe that’s what has me puzzled. My understanding is that something isn’t a disorder unless it interferes with your life or causes you distress. Introversion is not a disorder. (Explained nicely here, something you’ve probably seen already: http://romanjones.deviantart.com/art/How-to-Live-with-Introverts-Guide-Printable-320818879?q=gallery%3Asveidt%2F34464099&qo=3 )

    Having a panic attack when you think about leaving your apartment is a disorder because it interferes with making a living. Not being able to interact with people is a problem because we depend to some extent on a friends and family network as well as formalized relationships with strangers for our safety.

    But just being an introvert? On its own, not a disorder.

    And happy new year!

  2. Hi Alison,

    Thanks for commenting, and happy Christmas to you, too!

    Social anxiety seems to be diagnosed as a specific fear of social situations, rather than the introversion and fear of leaving home that you mention in your comment. Those are separate phenomena, and so while they have some features in common with it, they’re not actually what I’m discussing here. I should also perhaps say that I don’t think a dislike of socialising has to imply a rejection of interpersonal relationships in general. Socialising, after all, is only one of the means by which people interact with each other.

    The problem I have with the “causes distress” criterion for diagnosing disorder is that it takes no account of whether the distress may be appropriate for that individual in that situation. People with social anxiety may well be distressed in social situations. But that might just mean that they don’t like socialising, and should therefore avoid doing it, not that they have a “problem” that needs “fixing”. Many people do enjoy socialising, of course, but in my view that just means that it’s typical for the majority, not that it has to be mandatory for everyone.

    Thanks again for commenting, Alison, and take care!
    A.

  3. franhunne4u says:

    Isn’t a disorder a thing that affects your life in a way that you cannot live it the way you really WANT to? Like arachnophobia – I am merely disgusted by those 8-legged-ones – but some people cannot even leave their house for fear of encountering that “beast” … So social disorder is not diagnosed for little Jimmy who just does not like to go to school anymore, because it is boring, but it is diagnosed for Jackie, who WANTS to go to school, but cannot for the fear of having to talk to others and would rather die.

  4. I agree that introversion and social anxiety disorder are different things. My impression was that you were countering an article about social anxiety disorder with a defense of introversion. Possibly because the article conflated the two and you wanted to separate them?

    “People with social anxiety may well be distressed in social situations. But that might just mean that they don’t like socialising, and should therefore avoid doing it, not that they have a “problem” that needs “fixing”.”

    They don’t have a problem that needs fixing if avoiding socializing doesn’t cause them distress or interfere with their lives.

    Most people dislike elevators and aeroplanes. Most of us deal with this discomfort with little effort, and even for people who need to make more effort it’s not a particular problem because we don’t have to fly very often and elevator rides are short. If you hate elevators and aeroplanes so much that you can’t bring yourself to use them at all — you start to have a problem but stairs and trains exist and you will be in better shape. But if you have to turn down a job you want because you would have to ride an elevator to get to the 26th floor where you would work or because the arthritis in your knee means that even three flights of stairs are no longer possible for you, or if you can’t be with your dying mother because you can’t fly — now you definitely have a problem.

    Preferring not to socialize in person is a problem if it results in isolation and a fraying of your social network, if it means you can’t get work or you can’t do your groceries. Otherwise you’re right, it’s not a problem.

    Or what franhunne4u said.

  5. Hi Alison,

    Thanks for commenting again – I hope your Christmas brought you the things you wanted it to.

    I can reassure you on one point, at least – when I write about something I’m always sure to mention it by name, so there’s no need to worry if I was mounting a secret defence of introversion in my original post that I was somehow expecting you to guess at! My aim in writing the OP was to suggest that anxiety arising in social situations might be seen as a value-neutral emotion, rather than a disorder. And I then went on to suggest that paying attention to what the emotion signals (“you don’t like social situations”) and adjusting behavior accordingly (avoiding social situations) is a permissible alternative to trying to minimise or manage the emotion.

    I drew a distinction in the final paragraph of the OP between anxiety that interfered with things that someone needed to do (like going to work), and anxiety that interfered with things that they didn’t need to do (like going for a drink after work with their colleagues). So I am slightly confused as to why you are taking such trouble to stress, with reference to a fear of elevators and so on, a distinction that I had already discussed. We agree on this, and we agreed before you began typing your first reply!

    I linked to the diagnostic criteria for Social Anxiety Disorder in my last reply to you, and based on them I think that someone who was unable to leave the house would be unlikely to be diagnosed with that particular disorder. I think Panic Disorder With Agoraphobia would be the more likely diagnosis – and, in fact, the Social Anxiety criteria include a specifier to the effect that it should not be diagnosed if any other anxiety disorder is indicated. At the risk of annoying you by repeating myself, I’m going to stress again that these other problems which you keep raising do not fall within the scope of this post, which is about, and only about, social anxiety.

    I’m not quite sure what you mean by the phrase ‘fraying of your social network’. If you mean by it that someone who avoids social gatherings will be unlikely to have a large social group and won’t get invited to parties much then I agree. But if you don’t like large groups of people, not being part of a large group of people is a positive thing. I do not agree that social anxiety will lead to isolation, since a person who is socially anxious will experience no inhibitions or difficulties in maintaining intimate friendships on a one-to-one basis. Or, if they do, then they have some other form of problem. Difficulty maintaining interpersonal relationships is not social anxiety, in the same way that agoraphobia is not social anxiety, and so on.

    Thanks again for commenting, and take care,
    A.

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