What is Social Anxiety Disorder (SAD), and how is it diagnosed?
You’ve likely experienced social anxiety yourself. Think about how you might feel before giving a speech or prior to an important job interview. The DSM-5 (a manual which mental health professionals use for diagnosis) defines Social Anxiety Disorder as ‘marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others’.1 It will normally be diagnosed by a psychiatrist or psychologist, or sometimes a GP.
Why research SAD in women?
Several studies suggest that SAD is more common in women.2 There’s a feminist tradition of viewing these sorts of mental health diagnoses through a feminist lens – one example is Anorexia Nervosa.3 So, I wondered if doing the same with SAD would shed any light on why it appears to be more prevalent in women. And, as first-hand accounts of women with this diagnosis are largely missing from current research, I chose to interview seven women with SAD about their experiences. Taken together, their stories illustrate how twenty-first-century British society exposes women to the social conditions which give rise to being concerned with what others think of us, or worried that others are evaluating us negatively – in other words, social anxiety.
Can you say more about 1) what these social conditions are and 2) how they are conducive to women’s experiencing social anxiety?
Something which came up in nearly all participants' narratives was the imperative to be normal. Indeed, the women in my sample were notable in that they were all non-normative in some way, be that due to a physical health condition, neurodiversity, temperament, or another mental health diagnosis – they didn’t quite feel that they fit into mainstream society.
Another element which their accounts evoked was the imperative for women to be nice. Lisa Downing words this wonderfully in writing that ‘“not being nice” is a feature of being human for which women are particularly harshly punished’.4 One facet of being ‘nice’ is putting others’ wellbeing over our own, or being selfless. Indeed, participant Amy5 told me that her ‘social anxiety is probably tied to what I have been programmed to think, as a woman […] that my responsibility is to make other people comfortable’.
A further thread which ran through nearly all of the women’s stories was the extent to which women are watched and critiqued, both in terms of their behaviour and appearance. Inevitably, this stoked up social anxiety, and some of the women were able to stave it off by ‘putting up a face’ (Daniella) or adopting a ‘mask’ (Farah). However, this comes at a cost, for it hides how these women ‘really’ feel, and the wants and needs of their ‘real’ or ‘true’ selves remain unaddressed – they are literally rendered ‘self-less’.6
How does your book draw on anti-psychiatry?
Anti-psychiatry today arguably has a reputation for being a bit radical, even a condemnation of mental healthcare as a whole. But the strands I draw on are from the movement’s inception in the 1960s, which formed as part of a wider counterculture – another element of which was second-wave feminism. Despite being obvious bedfellows and sharing the same historical epoch, intersections of feminism and anti-psychiatry remain rather scant, and one of the book’s novelties lies in merging these two approaches and applying them to an under-researched mental health diagnosis: indeed, SAD has been dubbed the ‘neglected anxiety disorder’ by psychiatrist Michael Liebowitz.7
A large portion of the anti-psychiatry movement has been concerned with involuntary treatment, but this is not really germane to SAD – being socially anxious is unlikely to be grounds for detention under the Mental Health Act (being ‘sectioned’). Rather, I borrow some of the movement’s tenets to ask probing questions about the nature of being; who gets to decide what’s normal; and what we as a society frame as a mental disorder and why.
I take a lot of inspiration from psychiatrist R. D. Laing, notably his notion that insanity is ‘a perfectly rational adjustment to an insane world’.8 Applying this to my research, I argue that listening to socially anxious women’s accounts and trying to understand what’s happened to them might be a means of reframing their experiences of SAD as rational responses to the gendered world in which they find themselves. In so doing, we can question the idea that this form of mental distress is unique to them as individuals (this is called the ‘individual pathology model’ in sociology), and instead advocate for a wider view which considers their social context.
Many of these ideas form a cornerstone of Critical Psychiatry today, which aims to reform the field (as opposed to getting rid of it entirely), seeking to improve and individualise care so that, going forwards, it is of most benefit to those it intends to help.
Is SAD in women caused purely by social factors?
No. As my focus is on the social factors underpinning women’s experiences, it might, at a glance, appear that I’m denying the effects of other factors, but this would be a mischaracterisation of my stance. Indeed, like any mental health diagnosis, biological, psychological, and social factors are all at play.
Participants themselves had interesting viewpoints on this, many of them overtly discussing their perceptions of the role of biology. Ria said, ‘[W]e do have a hormonal fluctuation sort of in-built into our being’, and Ellen remarked that ‘I can be a bit more anxious on my period, but also, I’m mostly more anxious because of the way that men have spoken to me, in the past.’
In the spirit of integrating the biological with the psychosocial, other participants were very critical of the idea that the mind and body are separate, which is known in philosophy as ‘mind-body dualism’. Amy characterised this as ‘a fallacy’, and she emphasised ‘the significance of acknowledging that the whole body is interconnected and the psychological stuff affects the physical and vice versa’.
Other women told me how their SAD manifested in their bodies. Daniella said that her nervousness made her ‘feel queasy and nauseous, and dizzy’, while Farah described sweating, trembling, and feeling sick. A good example of social anxiety affecting the whole self – not just the mind or body – is outlined by an article from the Royal College of Psychiatrists entitled ‘Shyness and social phobia’. It tells us, ‘Other people may be able to see some of the signs of this anxiety – the blushing, stammering, shaking and trembling.' In turn, ‘You worry so much about looking worried that you actually do look worried.’9 A feedback loop of sorts is being set up here – emotions causing physical symptoms which then affect emotions – exemplifying the inseparability of the mental and the physical.
What’s the difference between Social Anxiety Disorder and shyness?
There’s not an easy answer to this, and where the distinction lies – and indeed, whether there is one – has been discussed by many figures across many fields over many years!
We do know that descriptions of shyness date back to Hippocrates (~400 B.C.E),10 but that it was not always associated with anxiety.11 The psychiatrists of the 1880s (or ‘alienists’, as then they were known) began to view it as a pathological phenomenon, and the early-twentieth century witnessed the diagnoses ‘Social Phobia’ and ‘Social Neurosis’ appear, first entering the DSM in 1965. Sociologist Susie Scott tells us that, since the 1980s, ‘[T]he diagnostic label has been applied to an increasing number of people who would once have been seen as “just shy”.’12 Other scholars, such as Christopher Lane, have challenged what they see as the medicalisation (in brief, making social problems or individual variation medical) of shyness.
In the book, my view on whether we should label experiences of shyness or social anxiety as Social Anxiety Disorder has to do with whether this serves the individual – is there utility for them in the diagnostic label?
This varied a lot between participants, some of whom pushed back against their social anxiety being characterised as a disorder, viewing the label as pathologising. I go into more detail on Farah’s viewpoint in this regard elsewhere, exploring her experiences of social anxiety as being a means of self-discovery and inspiration for making art.13
At the other end of the spectrum we have Amy and Phoebe, both of whom found utility in diagnostic labels. For them, psychiatric diagnosis offered a means by which they could make sense of their experiences or, in Amy’s words, ‘something to hang on to [...] and a thing to look up’.
References
1APA, Diagnostic and Statistical Manual of Mental Disorders [DSM-5] (Washington, DC: American Psychiatric Association Publishing, 2013) https://ebookcentral.proquest.com/lib/bham/reader.action?docID=1811753 [accessed 6 January 2021] pp.202-03
2Maya Asher, Anu Asnaani, and Idan M. Aderka, ‘Gender Differences in Social Anxiety Disorder: A Review’, Clinical Psychology Review, 56 (2017), 1–12 https://doi.org/10.1016/j.cpr.2017.05.004
3Interested readers: see the work of Susie Orbach.
4Lisa Downing, Selfish Women (Abingdon, Oxon; New York, NY: Routledge, 2019) p. 152.
5All participant names, in both my book and this article, have been changed to protect their anonymity.
6Downing, Selfish Women, p. 1.
7Michael R. Liebowitz, Jack M. Gorman, Abby J. Fyer, and Donald F. Klein, ‘Social Phobia: Review of a Neglected Anxiety Disorder’, Archives of General Psychiatry, 42.7 (1985), 729–36 https://doi.org/10.1001/archpsyc.1985.01790300097013
8Ronald David Laing, quoted in Larry Chang, Wisdom for the Soul: Five Millennia of Prescriptions for Spiritual Healing (Washington DC: Gnosophia Publishing, 2006), p. 412.
9Royal College of Psychiatrists, ‘Shyness and Social Phobia’, https://www.rcpsych.ac.uk/mental-health/problems-disorders/shyness-andsocial-phobia [accessed 6 September 2019].
10Hippocrates, quoted in Robert Burton, The Anatomy of Melancholy: What it Is, with all the Kinds, Causes, Symptoms, Prognostics, and Several Cures of It (London: William Tegg, 1854[1621]), p. 253.
11Christopher Lane, Shyness: How Normal Behavior Became a Sickness (Yale University Press, 2007) https://ebookcentral.proquest.com/lib/bham/reader.action?docID=3420940 [accessed 6 January 2021] p. 14.
12Susie Scott, ‘The Medicalisation of Shyness: From Social Misfits to Social Fitness’, Sociology of Health and Illness, 28.2 (2006), 133–53 https://doi.org/10.1111/j.1467-9566.2006.00485.x p. 135.
13Katie Masters, ‘Women’s Experiences of Social Anxiety Disorder: Privileging Marginalised Perspectives and Rewriting Dominant Narratives’, International Mad Studies Journal, 1.1 (2022), e1–21 https://doi.org/10.58544/imsj.v1i1.5244
Katie Masters is an independent scholar specialising in the sociology of mental health and gender studies. She completed her PhD at the University of Birmingham on women's experiences of Social Anxiety Disorder, and her doctoral research forms the basis of Feminist and Anti-Psychiatry Perspectives on 'Social Anxiety Disorder': The Socially Anxious Woman (Palgrave, 2024). Having previously taught at the University of Birmingham and the London School of Economics (LSE), she also hold as first-class honours degree in Physics. Her current work focuses on the intersection of mental health and strength sports, and she bridges these fields through her practical work as a strength/powerlifting coach, competitor, and referee.