Book Review

Shyness: How Normal Behavior Became a Sickness

N Engl J Med 2008; 358:539-540January 31, 2008

Article

Shyness: How Normal Behavior Became a Sickness
By Christopher Lane. 263 pp., illustrated. New Haven, CT, Yale University Press, 2007. $27.50. ISBN: 978-0-300-12446-0

This well-written book is a thoughtful examination of shyness and its relation to psychopathology. It reminds me of earlier books in this area, including Richard McNally's Panic Disorder: A Critical Analysis (New York: Guilford Press, 1994) and Isaac Marks's Fears, Phobias, and Rituals (New York: Oxford University Press, 1987). In fact, Marks receives an official acknowledgment in Christopher Lane's book. Although Lane claims to tackle mainly the topic of shyness and mental health, he also sheds light on recent developments in the official classification and nature of the field of anxiety disorders, dating back to the landmark changes that were introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980).

I agree with Lane that the estimate that one in five people has clinical levels of social phobia sounds very high indeed. I think the DSM planners tried to address this controversy by establishing a “generalized” or more severe subtype of social phobia in the revised edition of the DSM-III, which was published in 1987. Interestingly, though, pharmaceutical companies do not seem to make this distinction when they market their products, and they seem to promote the idea that social phobia is very common and that people with this disorder would benefit from pharmacotherapy with the particular drug or product they are marketing.

I find it interesting that the term “social phobia” has increasingly been replaced by the term “social anxiety disorder” in the official nomenclature. I don't believe that this is purely coincidental. Rather, it seems to me that if a general physician sees someone with a social phobia, the physician may recommend that the patient see a psychologist for behavior therapy, participate in Toastmasters, or use another self-help resource. However, if the same person receives a diagnosis of social anxiety disorder, a term that sounds far more serious, the physician might recommend more aggressive medical attention such as pharmacotherapy.

I also agree with Lane that shyness is not a “sickness” or a psychopathology. A few years ago, my research group conducted a study of the correlates of American adults with various degrees of self-described childhood shyness in a national mental health survey that was representative of the general population. Although we did find that an excessive level of childhood shyness was significantly associated with the likelihood of having severe adult social phobia, many subjects with excessive shyness did not meet the diagnostic criteria for any mental disorder. Furthermore, approximately half of the adults we studied who had severe social phobia did not report a history of excessive shyness. Other factors must come into play, such as very low self-esteem or a tendency toward self-criticism. One of the messages we took from this study was that it is important not to view shyness in young people as a form of mental disease requiring medical intervention and thereby potentially damage their self-esteem and self-confidence.

I enjoyed seeing the pharmaceutical marketing ads that are reprinted in Lane's book. I showed them to a psychiatry colleague, who could not believe that a drug company was trying to promote a particular therapy for a personality disorder. This colleague did not know of any approved drug that was efficacious for a patient with a personality disorder, despite the claims of the advertiser.

My main critique of Lane's scholarly work is that I think it somewhat unfairly targets Murray Stein's long-standing research on the prevalence and nature of social anxiety. I think that Stein would be the first to admit that telephone-based assessments conducted by lay interviewers in no way take the place of the diagnosis of a mental disorder made by a trained psychiatrist or clinical psychologist after a clinical interview. I believe that Stein's work was geared toward showing that social fears are commonly distributed among the general population.

In summary, I very much enjoyed reading Lane's thought-provoking book, and I would highly recommend it for psychiatry residents, graduate students in clinical psychology, and other mental health professionals in training who are interested in the field of anxiety disorders, and more broadly in psychopathology and general mental health.

Brian J. Cox, Ph.D.
University of Manitoba, Winnipeg, MB R3E 3N4, Canada
coxbj@cc.umanitoba.ca