Social Disadvantage is Not Mental Disorder: Response to Campbell-Sills and Stein

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Our target article argued that, although there are genuine social-phobic disorders wherein something goes wrong with mechanisms that generate social anxiety, most conditions satisfying DSM-IV social phobia criteria are likely not disorders but high-end, normal-range social anxiety overstimulated by contemporary social environments that demand high interaction and scrutiny while frowning on submission displays (1). We used the harmful dysfunction analysis of mental disorder to evaluate disorder status: according to this model, a disorder is a harmful failure of an internal mechanism to perform a natural function for which it was biologically designed. Social anxiety, we argued, is a normally distributed, biologically selected trait designed to protect individuals from risky behaviour in the social group. High-end designed levels of social anxiety may be less useful now than in ancestral environments—and even disadvantageous in current social environments—but such anxieties are part of normal human nature and not dysfunctions. In their thoughtful defense of DSM criteria, Campbell-Sills and Stein (2) acknowledge that some community cases of DSM-defined social phobia are normal temperamental variation rather than disorders. Nonetheless, they defend the classification of most DSM social phobia as disorder. They argue that the harmful dysfunction analysis is inadequate for judging disorder; that, anyway, most DSM social phobia is harmful dysfunction; and that, regardless, DSM social phobia is best classified as disorder for pragmatic reasons. We consider these points in turn.