This paper seeks to explain both the medicalization of Social Anxiety Disorder (SAD) and its newfound prevalence in the United States through Michel Foucault’s theory of discursive transformation. Drawing on the work of Allan Horwitz, it will be argued that the revolutionary shift within psychiatric discourse, from dynamic to diagnostic models of psychiatry, allowed mental disorders like SAD to be medicalized as genetic or biochemical dysfunctions of the brain. Furthermore, the modification of survey instruments and screening procedures subsequent to the adoption of the diagnostic model, expanded the boundaries of SAD discourse to capture more and more individuals within its purview. In conducting this analysis, the factors that gave rise to the conditions of possibility for these discursive transformations to emerge will also be enumerated. These include; the intradiscursive factors, or dependencies between the object, the operations, and the concepts of a single discursive formation; the interdiscursive factors, or dependencies between different discursive formations, and the extradiscursive factors, or dependencies between discourses and conditions external to discourse, such as economic, political or social changes (Foucault, 1978, 13). The potential consequences of this discursive transformation of psychiatric discourse will also be examined.
Keywords: Social Anxiety Disorder, Discursive Transformation, Diagnostic psychiatry, Dynamic psychiatry, Michel Foucault
Social Phobia, or Social Anxiety Disorder has become in recent years the most visible of mental illnesses 1 . The list of celebrity sufferers includes such notable superstars as David Beckham, Richard Gere, Russell Crowe and Brittany Spears (Armstrong, 2001). Anti-anxiety drugs that alter brain chemistry such as Paxil and Zoloft are becoming household names as pharmaceutical companies spotlight the disorder on U.S. television nationwide (Kalb, 2003). Indeed this disorder has become increasingly prevalent, both in the public imagination and in the eyes of psychiatry. The National Comorbidity Survey in the United States concludes that social anxiety disorder (SAD) has a lifetime prevalence of 13.3%. This makes SAD the third most common psychiatric disorder after major depression and alcohol dependence, and the most common anxiety disorder within the United States (Sheehan, 2001: 365). While the status of SAD as the mental illness du jour is difficult to deny, how did this disorder come to such prominence? Two decades ago SAD was considered marginal, infrequent, and rarely associated with meaningful impairment (Liebowitz, et al, 2000: 191). Today SAD is characterized as a “chronic and highly prevalent disorder often associated with serious impairment” (Ibid:191). How then did this transformation in psychiatric discourse occur?
This paper seeks to explain both the medicalization of SAD and its newfound prevalence in the United States through Michel Foucault’s theory of discursive transformation. 2 Through this Foucauldian lens, it will be argued that the revolutionary shift within psychiatric discourse, from dynamic to diagnostic models of psychiatry, allowed mental disorders like SAD to be medicalized as genetic or biochemical dysfunctions of the brain. 3 Furthermore, the modification of survey instruments and screening procedures subsequent to the adoption of the diagnostic model, expanded the boundaries of SAD discourse to capture more and more individuals within its purview. In conducting this analysis, the factors that gave rise to the conditions of possibility for these discursive transformations to emerge will also be enumerated. These include; the intradiscursive factors, or dependencies between the object, the operations, and the concepts of a single discursive formation; the interdiscursive factors, or dependencies between different discursive formations, and the extradiscursive factors, or dependencies between discourses and conditions external to discourse, such as economic, political or social changes (Foucault, 1978: 13). Finally, I will conclude the paper with some tentative thoughts on the possible implications resulting from this extension of the psychiatric gaze towards a greater proportion of the population.
Social Phobia or Social Anxiety Disorder, as it has increasingly come to be called, is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) as:
[A]n intense, irrational and persistent fear of being scrutinized or negatively evaluated by others. In patients with this disorder, feared social or performance situations typically provoke an immediate anxious reaction ranging from diffuse apprehension to situational panic. The types of fears and avoidance commonly associated with [social anxiety] are to some degree, experienced by most people. However, to meet the diagnostic criteria for this disorder, the symptoms must be severe enough to cause significant distress or disability. [Social anxiety] can be generalized, meaning that the patient fears many or most social interactions, or it can be limited to one or a few situations, such as public speaking or performing (Bruce,1999: 2311).
While the ultimate causes of SAD are still open to wide ranging debate, it is generally assumed that SAD is a result of adverse functioning of neurochemical systems in the brain (Skube, 2002; Horwitz, 2002a, 66). However, this was not always the case. Prior to the rise of diagnostic psychiatry, most mental illnesses were not viewed as biological impairments at all. In order to fully comprehend how this significant transformation in psychiatric discourse occurred, it is necessary to investigate the change from dynamic to diagnostic models of psychiatry and the conditions that allowed for this new discursive formation to emerge.
From the 1920s until the 1970s the dynamic model of psychiatry was the dominant discourse within the discipline, exemplified by its founder, Sigmund Freud.
For its time, dynamic psychiatry revolutionized the classification of psychiatric symptoms. The basic principle of dynamic classification was to link neurotic with normal behaviour and to classify both as variants of common developmental processes (Horwitz, 2002a: 41). This blurring between the normal and the pathological allowed for psychiatry to expand its purview to include a myriad of neurotic behaviours (hysteria, depression, anxiety, etc) previously considered outside the realm of the discipline (Ibid: 40). 4 These neuroses were believed to stem from universal childhood experiences; the “differences separating normal from abnormal behaviour were only matters of degree, not of kind” (Ibid: 41). Essentially, ordinary behavior stemmed from the same roots as the pathological; symptoms such as hysteria, compulsions or phobias were not viewed as forms of illness, but as exaggerations of normal behavioural functions (Ibid: 41).
The interpretation of symptoms was also revolutionized with the onset of the dynamic model. Dynamic psychiatry did not view overt symptoms such as hysteria or anxiety as direct indicators of underlying disorders, rather as symbolic clues to underlying psychological processes that could be understood principally in terms of psychoanalytic theories (Kirk & Hutchins, 1992: 77). For dynamic psychiatry, symptoms represented “chameleon like expressions of underlying unconscious conflicts” (Horwitz, 2002a: 45). The manifestation of identical symptoms in different individuals could represent different disorders, just as any underlying disorder could manifest itself through different symptoms. Thus the repression of deviant sexual urges might manifest itself in hysterical symptoms in one individual, or obsessive-compulsive behaviour in another. Overt symptoms did not indicate a specific underlying disorder that could be diagnosed the way a physical disease might. While the dynamic model dominated psychiatric discourse for almost fifty years, its inability to provide conclusive diagnoses of psychiatric symptoms would prove to be increasingly problematic. As will be shown, both interdiscursive and extradiscursive factors colluded to transform the conditions of existence of psychiatric discourse, allowing for the emergence of a new discursive formation in the guise of the diagnostic model.
During its period of ascendance, dynamic psychiatry linked itself closely with the discipline of clinical medicine. Indeed, as Horwitz argues, this gave the discipline a prestige of scientific validity that allowed psychiatry to distance itself from other rival discourses in the mental health field (2002a: 58). 5 However by the 1960s, the culture in medicine underwent a substantial transformation, adopting a methodology more congruent with classical conceptions of science (Ibid: 58). While practitioners of dynamic psychiatry continued to base their research on particular case histories, medical research began to view case studies as anecdotal and unscientific. According to Starr, medical research moved to a system predicated on specific disease entities that could be precisely defined and subject to scientific analysis. The use of large statistical studies, control groups, and double blind placebo trials of medication became the norm, thereby undermining the scientific legitimacy of the methodology employed by dynamic psychiatry (Starr, 1982). The dynamic system, with its view of manifest symptoms as “clues” or symbols” with variable meanings in determining the underlying causes of psychological distress made it virtually impossible to develop a well defined diagnostic system to be able to conduct large statistical studies with reliably measured disorders along the lines of clinical medicine. As Horwitz notes, “the symbolic, verbal, private, and interior essence of dynamic psychiatry was in many ways the exact opposite of the direct, objective, public, and overt emphasis of classical scientific methods” (2002a: 59). Thus psychiatry’s claims to preeminence within the mental health industry began to look suspect. The legitimacy of these claims to superiority were further compounded by competing discourses in clinical psychology, social work, and other emerging professions like marriage and family counseling, as medical training seemed increasingly irrelevant to the treatment of mental disorders (Kirk & Hutchins, 1992: 21). The ability of psychiatry to disqualify competing knowledges through appeals to scientific validity became increasingly untenable. 6 Thus the legitimacy of psychiatry itself became a critical factor in the eventual transformation from the dynamic to the diagnostic model.
While the crisis of legitimacy suffered by psychiatry at this time could be viewed as an interdiscursive factor in the transformation of psychiatric discourse, (the dependency between the discourses of scientific medicine and psychiatry), numerous economic, political and social, or extradiscursive factors, also contributed to changing the conditions of existence of psychiatric discourse at this time. These included the changing economic conditions of psychiatric practice, changing mental health politics, and the emergence of powerful advocacy groups. I will now briefly discuss each factor in turn.
In the era of dynamic psychiatry, most clients paid for therapy as an out of pocket expense. Payment was a transaction between the client and the therapist and so required no accountability to third parties (Horwitz, 2002a: 74). As the demand for psychotherapy in the 1970s increased, more insurance plans began to include therapy in their coverage, as did federal Medicaid (Ibid: 75). As Horwitz argues, insurance logic was incommensurate with the vague categorizations emphasized by dynamic psychiatry (2002a: 75). Third party payers needed a model of reimbursement and record keeping that reflected the discrete disorders of medicine. Mental health practitioners needed to provide insurers with concrete information on the types of illness they were treating and the results of these treatments, in order to adequately measure the efficacy of different treatment regimes. This type of categorical information simply could not be provided by the vague, symbolic characterizations of mental disorders made by dynamic psychiatry. Thus the dynamic model was increasingly incompatible with the measurements required by an insurance logic. In addition, the interests of pharmaceutical companies also challenged the limitations of dynamic psychiatry during this period. The Food and Drug Administration (FDA) would not approve medications for sale unless they proved to be effective in the treatment of specific illnesses. The drug industry therefore needed reliable, standardized categories of mental illnesses in order to demonstrate effectiveness to government regulators (Kirk & Hutchins, 1992: 78). Dynamic psychiatry did not lend itself to this organizational logic. Thus, the changing economic conditions in which psychiatry operated further problematized the dynamic model.
The political environment of mental health also changed during this period. The growing conservative political climate of the 1970s, characterized by the Nixon and Ford administrations, resulted in a reversal in policy by the National Institute of Mental Health (NIMH). Prior to the 1970s, the NIMH had engaged in an activist policy of preventative mental health measures aimed at addressing the broader social and economic determinants of mental health. By the late 70s, both Congress and research -oriented psychiatrists challenged the social activism of the NIMH in favour of an emphasis on the treatment of specific mental illnesses (Horwitz, 2002a: 76). Such a shift was more in keeping with the rhetoric of individual responsibility trumpeted by a new generation of neo-conservatives during this time. Research and funding priorities thereby shifted from the focus on broad social problems as determinants of mental illness, to neuroscience, related brain and behaviour research, and to the epidemiology of specific mental disorders (Ibid: 77). These research priorities, which looked for biological dysfunction as the determinant of mental illness, were anathema to the theories of dynamic psychiatry.
A further transformation in the social environment of psychiatry was the emergence of powerful new lay advocacy groups for the mentally ill. The most cogent of these groups was the National Alliance for the Mentally Ill (NAMI). This organization managed to wield substantial influence in both the U.S. Congress and the NIMH (Ibid: 77). The Alliance, whose membership was comprised mostly of the parents of mentally ill children, sought to classify mental illnesses as biological, brain-based diseases rather than as the results of faulty parenting or experiences in early childhood (Horwitz 2002b: 270). The NAMI argued for this reclassification of mental illness as biological in order to destigmatize the mentally ill and to connect mental disorders with notions of physical illnesses considered beyond the sufferer’s control (Horwitz, 2002a: 77). 7 This emphasis within the Alliance directly challenged the truth claims authorized by the theories of dynamic psychiatry. Furthermore, their advocacy efforts with the U.S. Congress and NIMH, the major funder of research about mental illness, only bolstered the urge to divert research money towards biological determinants of mental disorder.
What arose from this confluence of factors was a fundamental discursive transformation within the discipline of psychiatry. The alteration was not gradual, rather it was a total transformation of the system of psychiatric knowledge in a short period of time. By 1980, the vague, symbolic system of dynamic psychiatry concerned with unconscious processes was entirely replaced by the precisely defined, symptom based disease entities of the diagnostic system (Ibid, 57). In complete opposition to the dynamic system, the diagnostic model imported the medicalized framework of specific disease entities from clinical medicine. This framework emphasized different clusters of symptoms as indicators of distinct underlying diseases (Ibid: 2). Through these underlying organic pathologies, the diagnostic model seeks “the primary causes of mental illness in genetic and biochemical factors and so locates the pathological qualities of psychological conditions in the physical properties of brains, not in the symbolic systems of the mind” (Ibid: 3). This new system of knowledge was codified in the foremost psychiatric manual of the time, DSM III. As Kirk and Hutchins argue, the new manual:
[I]mmediately shaped almost all discussion of diagnosis not only in the United States, but throughout the world. References to it are ubiquitous in the mental health journals, where by 1990 over 2,300 scientific articles explicitly referred to it in the title or abstract. Most clinical discourse and psychiatric research are conducted within its confines (1992: 11).
Indeed with the introduction of DSM III, the diagnostic model was heralding its preeminence as the dominant discourse in mental health. The new discourse reaffirmed “American psychiatry to its medical identity and its commitment to scientific medicine,” proclaiming the “ascendance of scientific psychiatry” (Ibid: 7-8). With the arrival of DSM III, the diagnostic model did not become just one way of viewing mental illness among other possibilities, rather it would reflect the “assumed objective reality” of mental illness within the psychiatric community (Horwitz, 2002a: 5). A new authoritative discourse of American psychiatry, empowered to “speak the truth” of mental illness, had arrived.
The discursive transformation of psychiatry, from the dynamic model to the diagnostic, closely corresponds with Foucauldian notions of discursive change in a number of respects. The interdiscursive and extradiscursive factors discussed above transformed the conditions of existence of psychiatric discourse. These factors are what Sara Mills calls “support mechanisms,” intrinsic to discourse itself and also external, which keep the discourse in place (1997: 49). When these support mechanisms transform, so does the nature of the discourse. However the changes in the methodology of scientific medicine, the recording requirements of an insurance logic, the changing research and funding priorities of NIMH, and the challenge to the truth claims of the dynamic model by advocacy groups; none of these factors directly determined the emergence of the diagnostic model. Rather they changed the systems of functioning of psychiatric discourse constituting a “field of possibilities for the creation of theories, or themes, or what Foucault calls “strategies,” not all of which are actually realized” (Fairclough, 1998: 48). However as Foucault notes, these changes are not free or arbitrary; not any new discourse may have emerged out of the confluence of inter and extra discursive factors, rather these changes “operate in a realm which has its own configuration and which consequently does not offer limitless possibilities of modification” (1978: 23). The changing economic, political, and social terrain in which psychiatry operated may have put constraints or limits on what new type of discourse emerged, but they did not ultimately determine it.
In addition, the shift from dynamic to diagnostic models also corresponds with Foucault’s notions of the “places” where discursive or disciplinary change can occur. The importation of a medicalized framework from clinical medicine into the discourse of diagnostic psychiatry constitutes what Foucault deemed redistribution, or broader transformations that occur between two or more discourses, in which elements or concepts familiar to one discourse are imported into another (McHoul & Grace, 1997: 46).
Finally, the shift from dynamic to diagnostic models illustrates Foucault’s concept of discontinuity within the history of knowledge. Foucault conceived of bodies of knowledge as potentially discontinuous across history rather than necessarily progressive and cumulative (Ibid: 4). Foucault’s analysis of scientific change as discontinuous shows that it is “not seamless and rational; that it does not progress from stage to stage, getting closer and closer to the truth” (Ibid: 4). Indeed this discontinuity is evident in the transformation from the dynamic to the diagnostic model. There was no “new” knowledge base, or “scientific discovery” that advanced the discipline of psychiatry to accept the diagnostic model as a better representation of reality over the dynamic model (Horwitz, 2002a: 81). This is best illustrated by the way the diagnostic system appropriated the neuroses associated with dynamic psychiatry. While diagnostic psychiatry could not provide evidence that these neuroses were the result of specific neurochemical or brain based dysfunctions, the DSM III nevertheless reclassified these disorders as specific categories of mental diseases (Horwitz, 2002a: 72; Horwitz, 2002b: 270). Thus, the overt symptoms of dynamic psychiatry, such as depression, anxiety, or social phobia, that were regarded as outward manifestations of unconscious repression, became, under the diagnostic model, indicators of biological, brain based disease. While diagnostic psychiatry claims to have moved to a more scientifically inspired paradigm, the emergence of diagnostic discourse was not the result of continuous scientific progress, but rather an ad hoc, discontinuous affair.
We can now see how it was that social phobia, or social anxiety disorder came to be medicalized. Under the dynamic model the outward symptoms of social anxiety disorder would have represented a clue to some unconscious repression or childhood trauma. Under the diagnostic system, these overt symptoms became indicators of a neurochemical impairment in the brain, and consequently, amenable to treatment through medications that involve altering the chemistry of the brain (such as SSRI inhibitors like Paxil and Zoloft). However, while the medicalization of social anxiety can be explained by the discursive transformation from dynamic to diagnostic psychiatry, the contemporary prevalence of the disorder still needs to be elucidated.
The entry for social phobia in DSM III in 1980 stated that “the disorder is apparently relatively rare” (Horwitz, 2002a: 95). The Epidemiologic Catchment Area (ECA) study conducted in the early 80s confirmed this view noting a prevalence of 2.75 percent within community populations (Ibid: 95). How is it that the prevalence for this disorder went from 2.75 to 13.3 percent in the space of two decades? The reasons for this increase in prevalence has less to do with a rampant outbreak of mental illness within the American population in the last twenty years and more to do with intradiscursive changes within diagnostic psychiatry that affected the objects, operations, and concepts within the discourse.
With the advent of the diagnostic model came a subsequent transformation in the way studies of prevalence through community surveys were conducted. While the use of surveys to determine the prevalence of mental illness within community populations had been a standard instrument prior to the rise of diagnostic psychiatry, they underwent substantial transformation in regards to the determination of mental illness in populations after the publication of DSM III.
The Diagnostic Interview Schedule (DIS) became the principle instrument to measure prevalence rates after the institution of DSM III. The DIS measured specific diagnostic conditions in community populations that were supposed to be comparable to the major clinical entities found in the DSM III, such as depression, social phobia, generalized anxiety, etc (Horwitz, 2002a: 85). Due to the DSM’s focus on the diagnosis of overt symptoms, epidemiologists, could in theory, apply diagnoses developed for clinical patient populations to the broader population at large to provide reasonable estimates of the prevalence of mental illness (Ibid: 86).
However the differences between clinical patients and the general population were neglected in the application of this survey. The DIS merely catalogued symptoms; the interviewers had no discretion to consider the context or the causes for the manifestation of these symptoms within the general population (Ibid: 86). There were no degrees of pathology in the DIS, distinct mental disorders are either present or absent, depending on the symptoms displayed (Ibid: 86). Thus an individual who displayed the appropriate amount of recognizable symptoms would be designated as having a mental disorder, regardless of context or cause. The possibility that the manifestation of these symptoms may have been an appropriate response to a tragic life event (such as a death or a divorce) was not considered in the evaluation of the individual. The weakness of this approach was that it merely applied the symptom-based logic used in clinical practice to the wider population. The difference between these two populations is that clinical patients either seek out psychiatric care, or their behaviour is considered problematic enough to be brought to the attention of psychiatry through some agent of social control or through friends and/or family. Clinical patients themselves, or the people in close contact with them, have determined that their behaviour is distressing enough to seek psychiatric care. Clinical judgements provide a second level of screening as the individual sufferer is evaluated as to whether or not the clinician believes a mental disorder is present (Ibid: 90). In these settings, the context in which the symptoms emerged can be properly assessed. Therefore, the reliability of the diagnosis of a mental disorder to an individual can be made with a higher degree of confidence. The same cannot be said for the general population. The symptom-based community surveys do not provide sufficient checks to determine the presence or absence of a mental disorder within the individual participant. Therefore the amount of “false positives,” or individuals who outwardly display the symptoms of SAD, but due to context or cause do not possess the disorder, cannot be determined through these survey instruments.
Indeed the use of these survey instruments began to generate increasing rates of prevalence, with rates of depression, anxiety, and substance abuse sent soaring (Ibid: 86). Prevalence rates for social phobia were further exacerbated by a change in the required criteria for a diagnosis of the disorder. Instead of requiring “a compelling desire to avoid exposure to social or performance situations,” the criteria was altered to require only a “marked distress in these situations” to justify a diagnosis (Ibid: 95). By the early 1990s, the National Comorbidity Survey, based on the DSI, reported the prevalence of social phobia at 13.3 percent of the population, or one out of every eight Americans (Ibid: 86).
While the influence of the diagnostic model certainly affected the design of prevalence surveys in emphasizing a symptom based logic, what is perhaps more interesting are the changes in which the survey methods were applied. These changes constitute what Foucault termed derivations, or transformations within a discursive formation (1978: 11). 8 McHoul and Grace define this form of discursive or disciplinary change as that in which a discipline will “bring to bear operations which have normally applied to one of its objects and then apply it to another, thereby altering the character of the analysis of the second object” (1997: 45). In this case the lens of psychiatric diagnosis, originally fixed on clinical patients, was brought to bear on the general population. Due to the lack of screening checks in this shift, this expanded the horizon of psychiatry to capture more individuals within its gaze, thus problematizing a wider section of the population as social anxiety sufferers.
Indeed the expansion of this psychiatric gaze continues to this day. The manufacturers of Paxil, the most prescribed medication for SAD, offers a symptom-based self test on its website, the “Social Phobia Inventory Self Test (SPIN). As one journalist notes, responses that indicate even slight distress to the social and performance situations outlined in the survey are enough to be “digitally” diagnosed with social anxiety disorder (McIlroy, 2002). The manufacturer of Paxil states that only 5 percent of the population suffering from SAD seeks treatment. The company attempts to reach this 95 percent of the “untreated” population by broadcasting the prevalence rates for SAD to illustrate to the public how common the disorder actually is (Horwitz, 2002a: 95-96). Consequently, the adoption of a symptom-based logic not only expands the purview of psychiatry, but also potential drug markets.
Even the name change from social phobia to social anxiety disorder illustrates the discursive modification in the prevalence of the disorder. One group of psychiatrists lobby for the wholesale adoption of the term “social anxiety disorder” rather than “social phobia,” due to the formers’ ability to “connote a more pervasive and impairing disorder than is implied by the label social phobia” (Liebowitz, et al, 2000: 192). Thus the changes within the operations of psychiatric discourse established in the 1980s have persisted into the present day, continuing to capture more objects of knowledge within its expanding horizon.
While the use of symptom-based survey methods has increased the perceived pervasiveness of this disorder, it has seemingly not yet reached its limits in creating an ever more inclusive category of social anxiety disorder. The expansion of the clinical psychiatric gaze to the general population has begun to constitute younger and younger subjects as social anxiety sufferers. As Joli Jensen notes, an increasing number of young adolescents are being diagnosed with the disorder for displaying the overt symptoms, regardless of context or cause (2003: 5). 9 One child psychiatrist has even warned that “moodiness, oppositionality, and irritability are not normal teenage traits and should be treated as symptoms of an underlying disorder” (Ibid: 6). However the monitoring of the young for signs of social anxiety does not stop at teenagers. Increasingly, children as young as five and six are coming under the gaze of psychiatric medicine. Social anxiety scales for preschoolers have been developed to measure whether children are predisposed to the disorder. The Teacher Rating Scale of Social Anxiety (TRSA) is a Likert type teacher questionnaire of ten items for the identification of social anxiety (Bokhorst et al, 2001: 787). Sample questions include: “When he/she is asked to say something in front of the class he/she is...absolutely not afraid, not afraid, just as afraid as other children, afraid, very afraid,” with a higher score representing more social anxiety within the child (Ibid: 790). Parallel to the shift towards expanding the criteria required for SAD in adults, one set of diagnostic criteria for the existence of the disorder in young children include, “crying, tantrums, and freezing or shrinking from social situations with unfamiliar people”(Bruce, 1999: 2315). The use of symptom-based logic seems to have only just breached the surface of its possible objects of knowledge.
However the possible future of psychiatry reveals the potential to even further expand its scope. Recent developments in research on brain imaging and specifically on the “fear centre” of the amygdala, the part of the brain involved in processing emotional stimuli, has raised the prospect of identifying predilection for social anxiety in infancy (Conis, 2003). 10 Symptom based logic requires a degree of self-reporting, however brain imaging could, ideally, diagnosis a predisposition towards the disorder prior to the development of speech within an infant child. This penchant for early detection raises numerous ethical questions in regards to the extent of psychiatric intervention in human lives. As Nikolas Rose argues, the rhetoric that celebrates the potential of such technology to improve the health and quality of life of those predisposed to the risk of biological defect, “obscures the threat that new biological practices of control will coerce, restrict, and even eliminate those whose biological propensities are believed - by doctors, parents, or perhaps even by political authorities, to be defective” (2001: 2) While the possibility of parents or the state aborting a child based on a propensity to SAD is perhaps fanciful, there are real concerns with constituting children as potential sufferers of social anxiety so early in life. As the category of SAD expands to include more and more of the population within its purview, what comes to constitute “normal” versus “abnormal” sociality may also shift. In a commentary on the power of contemporary medicine, Foucault argues that what governs society are not “legal codes but the perpetual distinction between normal and abnormal, a perpetual enterprise of restoring the system of normality,” noting that today medicine is “endowed with an authoritarian power with normalizing functions that go beyond the existence of diseases and the wishes of the patient.” (Foucault 2004: 13). The quest to restore the child SAD sufferer to normality may involve a lifetime of intervention by medical authorities and other disciplinary institutions, subjecting the SAD labeled individual to possible pharmacalogical interventions, societal sanctions, exclusions, or other forms of social closure. Furthermore there is the question of how SAD labeled individuals will perceive themselves. As Foucault notes in his analysis of disciplinary power;
He (sic) who is subjected to a field of visibility, and who knows it, assumes responsibility for the constraints of power, he makes them play spontaneously upon himself. He inscribes in himself the power relation in which he simultaneously plays both roles (1979: 202-203).
In other words, the SAD labeled individual may internalize the power relations inscribed on herself, adopting techniques of self surveillance and self regulation to better accord with societal precepts of “normality.” Indeed, as Frank and Jones suggest, those labeled abnormal may come to embrace techniques and technologies by which they can shape themselves to become that which society holds out as desirable, adopting a “lifetime program of discipline” in an attempt to approximate some professionally defined version of normal (2003: 183). How would the early adoption of such “technologies of the self” affect childhood development, not to mention adult populations in general? While it is beyond the purview of this paper to fully pursue these questions, they are becoming increasingly relevant as psychiatry intervenes earlier in life. The case of social anxiety sufferers is just one small constituent part of the expanding horizon of psychiatric discourse.
In conclusion, I have attempted to outline the changes both intrinsic and extrinsic to the discourse of psychiatry to account for the medicalization and the increased prevalence of social anxiety disorder. Transformations within the discourse of psychiatry, between discourses psychiatry was dependent on, and the external environment in which psychiatry operated, altered the conditions of existence of psychiatric discourse, its system of functioning and insertion, resulting in a fundamental discursive transformation. This discursive transformation from a dynamic model to a diagnostic model transformed the way symptoms were interpreted and shifted the focus of psychiatry from unconscious, psychic processes to brain based, neurochemical dysfunction. In addition, the changes within diagnostic psychiatry regarding the measurement of the prevalence of mental illness brought operations originally fixed on clinical patient populations to that of the general population, resulting in a marked increase of rates for mental disorders like SAD.
Finally, I have provided some tentative, concluding thoughts on what consequences may result from the expansion of this psychiatric gaze. Indeed, the extension of this gaze has significant import for the way we view the world. As Foucault asserts, discourse narrows our field of vision, to exclude a wide array of phenomena from being considered as real, or as worthy of attention or as even existing at all (Mills, 1997: 51). As the dominant, authoritative discourse in psychiatry, the diagnostic model locates the causes of the outward expression of distressing emotions through internal, biological functions, thereby diminishing the validity of alternate ways of explaining and resolving emotional difficulties. This has resulted in an increasing tendency within psychiatry to medicate away unwanted feelings or emotions. The degree to which this becomes an acceptable response towards distressing life events or experiences is the degree to which we will have pharmacalized our very lives.
Armstrong, Lisa. (November 27, 2001).”Goodbye Shrinking Violets?” The Times (London).
Bokhorst, Koos., Goossens, Frits., & De Ruyter, Piet. A. (2001). “Early Detection of Social Anxiety: Reliability and Validity of a Teacher Questionnaire for the Identification of Social Anxiety in Young Children.” Social Behavior and Personality. Vol. 29, No. 8.
Bruce, Timothy. (1999). “Social Anxiety Disorder: A Common, Underrecognized Mental Disorder.” American Family Physician. Vol. 60, No. 8.
Conis, Elaine. (June 23, 2003). “Shedding Light on Shyness: Brain Imaging is Revealing Differences Between Timid and Outgoing People.” The Los Angeles Times.
Fairclough, Norman. (1998). Discourse and Social Change. Cambridge, U.K: Polity Press.
Foucault, Michel. (2004). “The Crisis of Medicine or the Crisis of Antimedicine?” Foucault Studies. Vol. 1, No. 1. December 2004.
Foucault, Michel. (1980). Power/Knowledge: Selected Interviews and Other Writings, 1972-1977. Gordon, C. (ed). New York, N.Y: Pantheon Books.
Foucault, Michel. (1978). “Politics and the Study of Discourse.” Ideology and Consciousness, No. 3.
Frank, Arthur & Therese Jones. (2003). “Bioethics and the Later Foucault.” Journal of Medical Humanities. Vol. 24, No. þ, Winter 2003.
Foucault, Michel. (1979). Discipline and Punish. Harmondsworth, U.K: Penguin Books.
Horwitz, Allan. (2002a) Creating Mental Illness. Chicago, IL: University of Chicago Press.
Horwitz, Allan. (2002b) “Culture, Harmful Dysfunctions and the Sociology of Mental Illness.” In Cerulo, K. (ed). Culture in Mind: Toward a Sociology of Culture and Cognition. New York, N.Y: Routledge.
Jensen, Joli. (June 13, 2003) “Let’s Not Medicate Away Student Angst.” The Chronicle of Higher Education.
Kalb, Claudia. (July 14, 2003). “Challenging Extreme Shyness.” Newsweek.
Kirk, Stuart & Kutchins, Herb. (1992). The Selling of DSM: The Rhetoric of Science in Psychiatry. New York, N.Y: Aldine de Gruyter.
Liebowitz, Michael., Heimberg, Richard, Fresco, David & Travers, John. (February 2000). “Social Phobia or Social Anxiety Disorder: What’s in a Name?” Archives of General Psychiatry, Vol. 57, No. 2.
McHoul, Alec., & Grace, Wendy. (1997). A Foucault Primer: Discourse, Power and the Subject. New York, N.Y: New York University Press.
McIlroy, Anne. (September 20, 2003). “High Anxiety.” The Globe and Mail.
Mills, Sara. (1997). Discourse. London, U.K: Routledge.
Rose, Nikolas. (2001).”The Politics of Life Itself.” Theory, Culture and Society. Vol. 18, No. 6.
Sheehan, David V. (December 2001). “Have Drug Companies Hyped Social Anxiety Disorder to Increase Sales?’ Western Journal of Medicine. Vol. 175, No. 6.
Skube, Daneen. (December 8, 2002). “Social Anxiety: It’s Nothing to be Afraid of.” The Seattle Times.
Starr, Paul. (1982). The Social Transformation of American Medicine. New York, N.Y: Basic Books.
1. The author would like to acknowledge the gracious assistance of Amber Alecxe for her comments and insights on preliminary drafts of this paper.
2. The purpose of this paper is not to argue the validity of whether SAD constitutes an actual mental illness, but to explain discursively how it was transformed into a medicalized, pervasive mental disease.
3. Medicalization refers to the process through which problems are considered to be discrete, biological diseases which professionals discover, name and treat.
4. Prior to the dynamic model, psychiatry was Asylum based, treating only the most serious of mental disorders, such as severe psychosis.
5. Horwitz argues that dynamic psychiatry’s close association with medicine allowed psychiatrists to justify their system of knowledge and to protect themselves from competitors such as social workers and psychologists through their status as physicians.
6. For a discussion of how claims of “scientificity” disqualify insurgent or subordinate forms of knowledge see Michel Foucault, Power/Knowledge: Selected Interviews and Other Writings, 1972-1977. (New York, N.Y: Pantheon Books, 1980)., 84-85.
7. Paul Rabinow has termed this type of collectivity “bio-sociality,” where individuals who identify themselves and their community through their biology challenge the vectors that lead from biological imperfection or abnormality to stigmatization and exclusion. Cited in Nikolas Rose, “The Politics of Life Itself.” Theory, Culture and Society. (Vol. 18, No. 6., 2001)., 19.
8. It could be argued that this discursive change constitutes a mutation in discourse, or the “displacement of the boundaries which define the field of possible objects.” However I believe the transfer in operations from clinical patients to the general population, which is critical in explaining the increased prevalence of mental disorders, is more characteristic of derivations within a discourse. See Foucault, 1978., 11-12.
9. Jensen notes that more and more U.S. college students are being medicated to deal with the stresses and frustrations of the academic environment.
10. It is curious to note how nascent the research is on how the brain may produce they symptoms of social anxiety disorder, twenty years after being categorized as a brain-based dysfunction.
Theory & Science