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RICHARD HALICKS, The Atlanta Journal-Constitution
December 9, 2007 Page: B4
http://strothmanagency.blogspot.com/2007/12/christopher-lane-q-in-atlanta-journal.html (best available link)
Christopher Lane is the Miller research professor at Northwestern University and the author of the newly published "Shyness: How Normal Behavior Became a Sickness."
His last book, "Hatred and Civility: The Antisocial Life in Victorian England," explored misanthropy, or people-hating, in the 19th century. "One of the things I was trying to do in this new book was think about what happened to misanthropes in the 20th and even 21st century," Lane said.
"As one psychiatrist that I interviewed put it, 'Well, they probably all got medicated, right?' Although his response was a bit glib, the risk is that indeed a lot of these emotions have been distorted or interfered with through medication."
Lane's book focuses on the process by which the psychiatric "bible" -- the Diagnostic and Statistical Manual of Mental Disorders" -- was revised in the 1970s and '80s by a task force of specialists appointed by the American Psychiatric Association.
The AJC spoke with Lane recently by phone. Here is an edited transcript of that conversation:
Q. You were able to review hundreds of documents pertaining to the 1980 revision of the Diagnostic and Statistical Manual -- documents that offered a glimpse of the process that few people had ever had before. What were some of the things that surprised you most in those files?
A. I was astonished at the carelessness of the psychiatrists and the degree to which their own self-interest often trumped scientific rigor. There are tremendous revelations of their own ambition and their willingness to sacrifice scientific rigor on the altar of expediency.
Q. For example?
A. Well, panic disorder, the first of the anxiety disorders to be included, was put in largely because [psychiatrist] Donald Klein had pushed for it very aggressively at a key meeting in Boston. There was quite a lot of dissent about it, and various key figures, such as Isaac Marks, an anxiety specialist in England, had said that this was a huge mistake. Marks was not invited to subsequent meetings. As he said to me, "The consensus was arranged by leaving out the dissenters." So the task force approved social phobia/social anxiety disorder even after Marks, who wrote the foundational document on it, insisted that it not be listed separately as a disorder. They didn't listen to him even though he was the leading authority on the problem at the time.
Q. It seems that shyness was not the same condition at the end of the 20th century as it was in the beginning, or even at mid-century. You note the irony that, at one time, we tended to admire reticence in people. Would you describe what happened, as your title states, to turn normal behavior into a sickness?
A. What happened was that the psychiatrists involved in revising the diagnostic manual got too carried away. One of the temptations on their part is to over-value a disorder so that it begins to look far more prominent and prevalent than it really is. So if they can say, "The disorder that I've researched afflicts one in eight Americans" -- even one in five, as some people now claim about social anxiety disorder -- then the media take the problem a lot more seriously. The coverage is extensive, and the drug companies are thrilled, because they can push for increased FDA licenses.
I document this process with several of the disorders, including social phobia, in DSM III. Chronic social anxiety is indeed a problem. Two percent of the population suffers from a form of acute social anxiety to the point where it's truly impairing. But of the 98 percent that we might call "worried well," many are also encouraged to second-guess their behavior and to ask themselves: Am I shy, or is this possibly social anxiety disorder? More generally, the risk -- indeed, the temptation -- on the part of the psychiatrist coming up with lists of the official symptoms, is to say, Let's conquer anxiety by adding more and more behaviors to the DSM -- public speaking anxiety, concern about meeting strangers, fear of people in authority, going to parties, and so on -- all of these are now listed in DSM IV. So the idea that they are limiting symptoms to truly impairing behaviors is, I think, impossible for them to maintain.
Q. Would you explain what this disorder is -- social anxiety disorder?
A. Social anxiety disorder is defined as an irrational concern about the judgments of other people. In more pop psychological terms -- this is not in the DSM -- that would include excessive self-consciousness and concern about what people think about one. In the DSM it is listed as an impairing disorder, meaning that it has to affect someone's life in a negative way. But most people would characterize these criteria as run-of-the-mill traits far from chronic or debilitating. Nevertheless, the official symptoms now include public speaking anxiety, embarrassment about eating alone in a restaurant, fear that one's hand will shake when one is writing a check, and undue avoidance of public restrooms. It's an extraordinary combination of routine behaviors and very prevalent, common fears among people, with language that represents the entire picture as a biological dysfunction, rather than anything to do with psychology.
Q. There must be people on the other side of this argument who say, if we've identified a condition that affects one in eight people in this country, we've made great strides forward. Where's the middle ground?
A. It's surprisingly difficult to find. I debated with Robert Spitzer [who headed the task force that rewrote the diagnostic manual] on the BBC, and he came out with his usual line: "I'm more concerned about all the people who are not being diagnosed and are not finding treatment than with those who are overdiagnosed." The leading specialists continue to stress that one in five Americans might suffer from this affliction, but certainly one in five Americans is not on some kind of treatment. So the specialists would like to diagnose even more people so they can receive drug treatments and thus, presumably, be free of anxiety about the symptoms listed above.
On their side, they would counter that they are deeply concerned about an increase of anxiety across the board, and I would add, in agreement here, that there are indeed very serious reasons why we are seeing increased rates of anxiety in the population -- anxiety that I am not calling a disorder or a biological dysfunction. The first reason is doubtless the pressure on parents and on children to succeed, as well as to flourish in what is a very competitive world with all kinds of insecurities in the employment market.
There are also increased rates of anxiety in the population as a result of terrorist attacks. And 9/11 played a surprisingly big role in the increase of drug-related advertising that we saw shortly thereafter. [Drug maker] GlaxoSmithKline was extraordinarily opportunistic here in running millions of dollars worth of ads in October 2001, right after the 9/11 attacks, with women saying, "I keep fearing that something awful is going to happen."
Q. Which brings us to the role that the pharmaceutical business plays.
A. For starters, they rely on researchers in psychiatry to evaluate their drug trials, and so there is a massive conflict of interest because the researchers are very keen that their anxiety disorder centers, and so on, continue to receive funding, which often comes directly from the drug companies. In terms of their own tenure at universities, the researchers have come to rely on that degree of external support. At the same time these experts are working for sometimes a dozen drug companies at a time, and they're very reluctant to bite the hand that feeds by saying, "We're actually seeing poor or even negative results here." There are lots of ways that the drug trials are limited in time so that the side effects that people experience, and there are many, go unrecorded, or are differently represented.
For instance, and this is a classic, suicide ideation -- increased thoughts about suicide -- is often rewritten as "labile personality," which means an unpredictable personality or, simply, mood swings. That doesn't begin to register how severe those side effects are. The FDA at the same time relies on these experts and increasingly can't find people who are expert who do not have ties to the drug companies. So they proceed on the assumption of neutrality, based on the fact that these experts have ties to virtually every drug company going, and, therefore, they're not going to have a particular preference for one, which I think is extremely alarming, but it's an indication of our troubling state of affairs.
If you want to ratchet it up a notch, we have more lobbyists for the drug companies than we have members of Congress. We have an estimated 625 full-time lobbyists. One has to ask, how are they kept busy? What are they doing? That's an awful lot of people.
Q. Marketing is a huge element of this, yes?
A. Yes, it is. One particular thing I talk about in the book is the $92 million that [Paxil maker] GlaxoSmithKline spent in the year 2000 alone pushing what they called a public awareness campaign for social anxiety disorder. They didn't have their fingerprints on it or put their name on it. But they spent $3 million more than was spent on pushing Viagra that year on what Glaxo dubbed a public awareness campaign that would make people second-guess their behavior and view it in pharmaceutical terms.
The campaign was called "Imagine being allergic to people." And the idea was to catch the shy and encourage them to view their behavior as something more: "Am I just shy, or is this potentially social anxiety disorder?" Once you have people doubting themselves and considering their behavior in that light, then "ask your doctor about Paxil as a suitable remedy" seems almost an imperative if one cares about one's health and that of loved ones. This was part of the second wave of advertising Paxil as the remedy for social anxiety disorder. There were 1.1 billion media impressions that year for its new drug treatment. It was everywhere, on the television, in popular magazines, everywhere you went.
What they don't record but what we now know is that Paxil is one of the worst antidepressants in terms of withdrawal symptoms. The drug company encourages people to taper their doses very carefully when they're coming off the drug, and this is indeed medically wise. But even so, a very large number of people experience chronic mood swings when they come off Paxil. What the drug does is make it very difficult for the body to distinguish between routine stress and chronic anxiety, so it tends to clamp down on both, and that's a very serious problem, especially because it takes the brain and central nervous system a long time to recover. All this is very paradoxical, too, if you think that people can be going through this anxious time over a drug that was meant to reduce their anxiety about going to parties and concern about figures in authority.
Q. So many people look at SSRIs as miracle drugs. Do you think most people are aware of what drugs such as Paxil and Zoloft and Prozac and Effexor can do?
A. I think we have massively underestimated the effects of these drugs both in terms of their medical side effects but also in social and cultural terms. By that I mean the widespread emotional blunting, including sexual dysfunction, that is prevalent when people are on these drugs.
Q. What do you mean when you say emotional blunting?
A. The experience that some people have that they are wandering around in a chemical haze, and they do not feel like themselves. Their emotions are blunted, distorted or numbed by the drugs themselves. This goes back to what I was saying a moment ago: The drugs aren't sufficiently intelligent to discriminate between routine anxiety and chronic anxiety. So there's a strong likelihood in many people that the meds will also begin to interfere with their normal range of emotions.
Q. You took great exception with the exclusion of psychoanalysts from the 1980 DSM revisions. Why was it important that the Freudians be part of the process?
A. Because psychotherapists and psychoanalysts have an ability to talk about our minds in ways that are far more sophisticated than we're finding with neuropsychiatric discussions of the brain. The presumption in psychoanalysis is that a lot of our problems are not readily available to us. We can't simply fix them by going to a few sessions of therapy -- maybe cognitive behavioral therapy, which is one of the latest interests, because it seems very efficient and very rapid. Psychoanalysts say that the problems are often far more deep-seated and not something that we can put our fingers on always with great rapidity. It matters that we allow treatments to occur over a longer period of time.
PUT YOUR MOOD TO THE TEST
This is the Geriatric Depression Scale devised by Dr. Jerome Yesavage, director of Stanford University's Aging Clinical Research Center, and colleagues. Yesavage notes that a couple of the questions are specifically aimed at older adults but that most of the questions apply to all ages.
Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life?
YES NO*
2. Have you dropped many of your activities and interests?
YES* NO
3. Do you feel that your life is empty?
YES* NO
4. Do you often get bored?
YES* NO
5. Are you in good spirits most of the time?
YES NO*
6. Are you afraid that something bad is going to happen to you?
YES* NO
7. Do you feel happy most of the time?
YES NO*
8. Do you often feel helpless?
YES* NO
9. Do you prefer to stay at home, rather than going out and doing new things?
YES* NO
10. Do you feel you have more problems with memory than most?
YES* NO
11. Do you think it is wonderful to be alive now?
YES NO*
12. Do you feel pretty worthless the way you are now?
YES* NO
13. Do you feel full of energy?
YES NO*
14. Do you feel that your situation is hopeless?
YES* NO
15. Do you think that most people are better off than you are? YES* NO
Answers in bold* indicate depression. Each person's situation is different. But generally speaking, a score of more than five points is suggestive of depression and warrants a follow-up interview. Scores greater than 10 are almost always indicative of depression.
Photo
Author Christopher Lane, below, argues that psychiatrists have turned ordinary emotions into mental disorders, and that social anxiety disorder is a textbook example. Lane believes that many cases of the disorder are simple shyness that shouldn't be treated with drugs.
Photo
American Journal of Psychiatry
This ad for the antidepressant Zoloft appeared in the American Journal of Psychiatry in August 2003.
Copyright 2007 The Atlanta Journal-Constitution
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