I was watching a TED talk on the power of introversion by Susan Cain and feeling good about the fact that someone had finally given introverts a reason to feel positive about a form of behaviour that, traditionally, has been tolerated but never encouraged. Indeed, as Cain points out, social, educational, and workplace settings favour extroverts over introverts even though skills, knowledge and abilities may be on a par, or even superior in introverts. Of course introverts are a minority but not so small a minority that anyone could attempt to use it as some sort of justification for overlooking us.
Susan Cain champions introverts eloquently, entertainingly, and bravely – given that she does not favour the lime light – but, worthy as I may think the cause to be, it is not really what captured my attention. It was an almost off the cuff remark she makes quite early in her talk when she differentiates introversion from shyness: “it’s different from being shy. Shyness is about fear of social judgement. Introversion is more about how you respond to stimulation”.
That statement hit me like a sledge hammer! Why did the speaker feel it necessary to make that distinction? I have no difficulty with the definition, but what purpose was there in differentiating shy people from introverts? In doing so, has she not done exactly what others have done in differentiating introversion from extroversion? Isn’t it the case that she has created an opportunity to favour introversion over shyness in much the same way that extroverts have been favoured over introverts? Do we have to wait now for a champion of the shy to point out that shy people too have a lot to offer if we could just get society to stop putting us in the pigeon hole labelled “fearful of making a fool of themselves in public”. It might be useful to a circus administrator charged with the job of hiring clowns, but then some shy people function very well in public behind a mask and those that don’t probably wont be applying anyway.
Every time we make a distinction, we are creating an opportunity to treat one group differently from another. Tension and conflict cannot exist unless differences are identified. That doesn’t mean we should never make distinctions but I think it does mean that we have an ethical responsibility to think very carefully about the potential consequences of our desire to sub-divide and categorise. Even though a desire to taxonomise may have the most benign of motives (eg the desire to better understand), we have to consider unanticipated outcomes of exposing differences and if there is potential for negative consequences to any part of the domain of interest, then we have an obligation to consider the harm we might do even when a holistic net benefit can be demonstrated.
Of course, differentiation is not always done consciously and deliberately and it may take not much more than the attachment of a label to turn something we already know subconsciously and informally, into a concrete difference. It’s in our nature to try to simplify complex things by categorisation and labelling, and I’m not sure if it’s possible to stop doing that but the collateral damage that can result from our desire to control complexity suggests to me that we must, at least, start to quantify that potential for incidental harm and take steps to minimise the threat when the risk of harm passes some threshold. Incidental harm, in this context, includes the effect of putting a target (in the form of the label) on members of the group in much the same way that some ethnic, religious, and other psychosocial minorities have been targeted for negative attention. I was tempted to include a more detailed list of what I consider to be psycho-social minorities here until I realised I was falling into the same pigeon holing practices I am baulking at!
Let me return to what prompted this musing and say that I am not opposed to differentiating shyness from introversion if, in doing so, both groups derive some benefit. I simply could not see what benefit was gained, other than the purely didactic satisfaction accruing to the speaker. Imagine an article in ‘Good Housekeeping’ discussing what its house proud readers contribute to a happy family and pointing out that having an impeccably clean home is not the same as being obsessive compulsive in your behaviour. So being house proud does not mean you are obsessive compulsive (though you probably are) and being introverted does not mean you are shy (though you probably are). Perhaps the distinction is intended to be a diagnostic aid. We don’t typically seek treatment for ‘house proudness’ but we might if it was called an obsessive compulsive disorder and we might think introversion is more akin to eye colour or height and not something that is amenable to treatment. On the other hand, shyness, like OCD, is something people do seek treatment for so maybe that’s why it’s worth differentiating it from intractable introversion.
I thought about this and wondered if there could be clinical advantages in knowing whether someone is shy or simply introverted. Clearly, there are significant advantages in providing targeted treatments to patients whenever possible. We would start to have grave doubts about the competence of a medical profession that prescribed two Bex, a cup of tea, and a good lie down for every patient regardless of symptoms. So, I did a quick literature search to establish what can be done for shyness in particular. The first thing to contend with is more differentiation. Shyness is social phobia, more or less! They are so closely related, I find it difficult to understand the need for the distinction. At least, the distinction between introversion and shyness is clear and my only quibble is over the circumstances in which we feel the need to make it. If there is any difference between shyness and social phobia (or social anxiety disorder as it is also called – SAD really!), it would appear to be in terms of the degree to which ‘sufferers’ suffer with it. Alarmingly, social phobia is also called ‘avoidant personality disorder’ which, it seems, was thought to be a different condition until some researchers reported this (Acta Psychiatr Scand.2005 Sep;112(3):208-14):
Avoidant personality disorder and social phobia: distinct enough to be separate disorders?
Yale University School of Medicine, New Haven, CT 06519, USA.
Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone.
Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables.
Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone.
These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.
‘Alternative conceptualisations of the same disorder‘ illustrates the parallel universes in which different clinicians live and the reason we should take greater care with our attempts to better understand our world and avoid unnecessary divisions within it. There is no specific treatment for shyness and it is treated in the same way that any other anxiety disorder is treated, including obsessive compulsive disorder! The approach to treatment may vary but not because of any refinement of the classification beyond the broad class of ‘anxiety’. If it differs, it will be because of individual differences between people and the last thing a person seeking treatment needs at that point is to be pigeon holed as being the same as a million other people and treated in the same way. Therefore, I would argue that, once a process of classification has reached the goal of ensuring a person gets to see the appropriate specialist, any more refined classification is actually counter-productive and leads me to the same conclusion in a medical context as I had reached regarding taxonomies in general. If there is no benefit or, more importantly, if there is the potential for harm by exposing differences, then do not do it.
Serendipitously, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has just been released (replacing the 20 year old fourth edition) and I sought to reference it as part of the literature search for this musing. Unfortunately, it is not yet accessible (at least to lay people) but I did come across a news item in the Canadian Medical Association Journal (CMAJ) about it dated 15th May, 2013. It includes this paragraph:
The changes have already provoked criticism from a previous editor of the manual and other leading psychiatrists (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4371). They contend the new edition will pathologize normal emotional reactions. The new manual, for example, opens the possibility for doctors to diagnose grief following bereavement as a depressive disorder.
The article referenced in the above quote is accessible only to subscribers but it is by Paul Kudlow and titled “The perils of diagnostic inflation”. Diagnostic inflation refers to increasing the numbers of people falling within specific classifications by changing the boundaries of the classification or by introducing new classifications to capture areas not previously classified. An example is given in the quote above.
Allen Frances (chair of the DSM-IV Task Force) expresses his concern in the following terms:
Unless corrected, DSM 5 may create millions of newly mislabeled ‘patients,’ with resulting unnecessary and potentially harmful treatment, stigma, and wasteful misallocation of scarce resources.
His concerns are about mislabelling and, of course, they are specific to diagnostic classifications but they reflect my concerns about unnecessary labelling in the more general context. I might mention, in closing, that my partner in life has had the benefit of reading Susan Cain’s book ‘Quiet – The Power of Introverts’ and she assures me that Ms Cain’s differentiation of shyness from introversion is justified by a thorough explanation of the distinction not evident in the casual aside she makes of it in her talk. I accept that she may have good reason for the distinction but the fact remains that it isn’t evident in her talk and that emphasises the need to explain the necessity whenever we feel compelled to highlight differences. There need be no question of mislabelling and there may be positive value in the distinction, but my point is simply that the value must be clear or the distinction should not be made.