How Shy Became Sick

By Deanna Isaacs
Chicago Reader | Published February 14, 2008
[link to article]

Christopher Lane set out a few years ago to write a book about people who hate people. Lane, a Victorian literature scholar and professor at Northwestern, had already published a book on misanthropes in the Victorian era, which he says “had a relatively high tolerance for eccentrics, reclusives, hermits, and scolds.” He wanted to carry his study into the 21st century. But when he began asking psychiatrists about the fate of contemporary misanthropes, the response he got was that they’d likely be medicated. Behavior considered part of the normal spectrum in the 19th century, Lane says, had in our time become a mental disorder requiring treatment with prescription drugs.

And misanthropy wasn’t the only behavior that had become an illness. It looked to Lane like the much more common trait of shyness, which Victorians had actually valued as a sign of modesty and a contemplative mind, had been transformed into something called social anxiety disorder. People who dreaded giving speeches, or blushed when they were the center of attention, or who, like Lane himself, needed a certain amount of their own company, were popping pills that promised to turn them into breezy extroverts. How had this happened?

With the support of a Guggenheim fellowship, Lane took the 2005-’06 school year off to see if he could find out. The resulting book, Shyness: How Normal Behavior Became a Sickness, was published in October by Yale University Press. History with an unabashedly Freudian point of view and a dash of lit crit, it’s been greeted with cries of foul from some quarters of the psychiatric establishment and has elicited reviews ranging from dismissive to glowing—including, most recently, a thumbs-up in the January 31 edition of the New England Journal of Medicine.

There wasn’t any question about when things changed. In 1980, the American Psychiatric Association published the third edition of its bible, the Diagnostic and Statistical Manual of Mental Disorders, and revolutionized the profession. Six years in the making, DSM III sought to rescue a medical specialty that was falling into disrepute. Studies showed that psychiatrists were more likely to give the same patient different diagnoses than to agree, and many of them blamed the existing version of the DSM, which consisted of short, vague descriptions of 180 ailments. Lane, taking a longer view, says DSM III was a turning point in what had been a hundred-years war between neuropsychiatrists and psychoanalysts: the neuropsychiatrists got the upper hand and Freudian theory effectively got the boot.

DSM III was purged of almost all psychoanalytic language, including most references to that most common of psychoanalytic conditions, neurosis. It sought to standardize diagnosis by including a checklist of symptoms (a certain number of which had to be present) for each illness and splintered broad diagnostic categories into multiple ailments. DSM III introduced an astounding 112 new disorders, including social phobia—defined as “a persistent, irrational fear of, and compelling desire to avoid, a situation in which the individual is exposed to possible scrutiny by others and fears that he or she may act in a way that will be humiliating or embarrassing.” Over the years, social phobia has become better known as social anxiety disorder.

The environment for these dramatic changes included two huge behind-the-scenes forces: insurance companies, which were balking at the cost of long-term talk therapy, and drug companies, which had been selling antipsychotics and tranquilizers since the 1950s and, as has been observed by other writers, including British expert David Healy (The Antidepressant Era, 1997, Harvard University Press; Let Them Eat Prozac, 2004, NYU Press), were looking to reach a broader market.

But their influence was indirect. Lane was interested in exactly what had transpired during the six years of meetings, correspondence, and discussions leading up to the publication of DSM III. When he requested access to the APA’s records, he says, he was told that they couldn’t be found and might have been lost during a move. He tracked down the author of a paper that quoted from some of those records, hopped a plane to Berkeley to copy what materials the author had kept, and then let the APA know he was proceeding on the basis of what he had. At that point, he says, the APA located its papers and gave him permission to study them. Lane also landed an interview with Robert Spitzer, the prominent Columbia University psychiatrist who’d spearheaded the DSM makeover.

What Lane found shocked him. As he sees it, Spitzer stacked the 15-member DSM III task force with “like-minded” academicians with an anti-Freudian bias. The task force met for four years, he notes, before a single psychoanalyst was invited to join it (and he resigned after two years). Lane tells me the process, which was supposed to establish psychiatry as a solid science, was itself “highly unscientific.” The task force spun out one new disorder after another, sometimes “knocking out the list of symptoms in a matter of minutes. . . . Almost overnight, shyness and many other routine moods and ailments became bona fide disorders.”

The DSM doesn’t prescribe treatment, but Lane writes that “in creating dozens of new illnesses and altering the wording of countless more, the updated manual certainly helped psychiatry to jump tracks” from psychodynamic to neurochemical. Spitzer’s task force executed an “end-run around psychoanalysis,” he tells me, and now “the rewriting of psychiatry’s history has been so complete, it is as if Freudianism never happened.”

DSM III was promoted as the vehicle that would turn psychiatry into “a pristine scientific entity.” When a Dr. Peter Janulis protested the dropping of psychoanalytic language in the article “Tribute to a Word: Neurosis,” in the Archives of General Psychiatry, Spitzer and his colleagues were sufficiently confident to respond with a poem, which the journal also published:

Could bad cognitions be the hex,
instead of conflicts over sex?
A transmitter lacking in your brain
may lead to lots of psychic pain.

The condition Freudians had known as anxiety neurosis had become seven separate illnesses: agoraphobia, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, simple phobia, and social phobia.

Lane claims that from the beginning, social phobia—which was characterized, for example, by fear of speaking or performing in public or using public toilets—was hard to distinguish from the ordinary shyness felt by about half the general population. When DSM III was revised in 1987, he writes, it exacerbated the problem by relaxing the criteria. According to Lane this revision was “instrumental” in turning a disorder termed “relatively rare” in the manual into one that could affect almost everyone on the planet. In 2000 an article in the Harvard Review of Psychiatry called social phobia the third most common psychiatric disorder, behind only depression and alcoholism.

By the time a fourth edition of the DSM was published in 1994, the number of ail­ments had mushroomed to 350, some of them hard to distinguish from one another. Social anxiety disorder, for example, overlaps broadly with something called avoidant personality disorder, characterized in part by avoiding social situations and fears of being embarrassed. A clinician who’s not sure which one to use might tag a patient with both, which Lane argues would cause that patient to be counted twice in disorder-incidence statistics, thereby inflating them.

The new disorders were a marketing bonanza for the pharmaceutical industry. “Before you sell a drug, you have to sell the disease,” Lane writes. Take Paxil, for example—one of a new generation of antidepressants, such as Prozac and Zoloft, now known collectively as selective serotonin reuptake inhibitors, or SSRIs. When Paxil failed to outperform existing drugs in initial trials on hospitalized patients in the 1980s, its maker, Beecham, considered shelving it. But instead it was retargeted to patients who weren’t as ill, and in 1999 the FDA made Paxil the first drug approved to treat social anxiety disorder.

Paxil’s owner, by then SmithKline Beecham, began promoting Paxil as a remedy for ailments that it estimated affected “around 90 million adults in North America and Europe . . . at any one time.” The trade paper PR News reported that the manufacturer aimed to position social anxiety disorder as a “severe medical condition,” and Paxil’s product director told Advertising Age that “every marketer’s dream is to find an unidentified or unknown market and develop it. That’s what we were able to do with social anxiety disorder.” An advertising campaign included direct-to-consumer print ads with headlines like “Imagine being allergic to people.” Lane reports that in 2000 the manufacturer (which was about to become GlaxoSmithKline) spent $92 million promoting awareness of social anxiety disorder. In 2001, 25 million new Paxil prescriptions were written. By 2004 annual sales were $2.7 billion worldwide.

These days Paxil’s Web site offers a do-it-yourself quiz that can tell you in a flash whether you might be suffering from social anxiety disorder. All you have to do is respond to 17 statements like “Sweating in front of people causes me distress,” and “I avoid going to parties” on a scale of zero to four.

Lane says 67 million Americans have taken Paxil 67 million North Americans have been prescribed SSRIs; 18.5 million of them got Paxil. Because the drug companies are the major funders of medical research, most of the studies the public hears about are ones that support drug company interests, and Lane argues that Paxil has problems that its manufacturer knew of long before the public did. In clinical trials, side effects ranged from drowsiness to sexual dysfunction, and though SSRIs were marketed as easier to quit than their competitors, Lane says there are accounts of patients experiencing withdrawal symptoms that included worse anxiety than they’d had to begin with. Until recently it was also being prescribed for children and teens, despite little published research.

New York attorney general Eliot Spitzer sued GlaxoSmithKline for fraud in 2004, charging that it had suppressed studies about Paxil’s effects on children and adolescents; the company settled that suit for $2.5 million. More recently, on February 6, Senator Charles Grassley of Iowa wrote GlaxoSmithKline asking for documents he believes might show the maker knew as early as 1989 of a heightened suicide risk among young adults taking Paxil, though it didn’t alert the public until 2006.

Lane sees evidence of a backlash against the drug companies in popular culture and, in literary critic mode, devotes a chapter in Shyness to several novels (including Jonathan Franzen’s The Corrections) and Zach Braff’s 2004 film, Garden State, whose 26-year-old protagonist has been too medicated to feel anything since he was ten.

Nearly 124 million prescriptions for SSRIs were written in the United States in 2006, although—this is startling—according to a study reported in the journal Prevention & Treatment in 2002 and cited by Lane, about 80 percent of the time patients were as responsive to placebos as they were to the antidepressants.

“The mind is formidably complicated; there’s so much guesswork in how people will respond to a drug,” Lane writes. “We see it in articles that say ‘It’s a question of finding what works.’ People, including children, are cy­cling through different brands and doses, with wildly unpredictable re­sults.” And, he adds, cit­ing various sources, “there’s no scientific evidence that low serotonin levels cause any of the problems SSRIs are said to remedy, including depression. Serotonin levels fluctuate within individuals and vary from one individual to another, and no one actually knows what constitutes a perfect chemical balance in the brain. There’s a relationship between serotonin and mood, but it’s difficult to characterize it as causal.”

In December Shyness got a whack from literary critic Frederick Crews in the New York Review of Books. Describing the tome as “polemical”—a fair assessment—Crews argued that Lane was mistaken in his assumption that the “shapers of the DSM have been deliberately tilting the manual away from humane psychotherapy and toward biological and pharmaceutical reductionism.” He slammed Lane’s “conspiracy-minded” book as “too uncomprehending and partisan to be taken seriously.” APA research director Darrel Regier agrees with Crews: he says Lane “kind of posed as a historian, coming into the APA” and using a “selective collection of documents to basically support a view he had before he ever arrived.” Regier says Lane’s book is “wistful for a return to psychoanalytical concepts” and that Lane, in arguing that shyness has been turned into an illness, ignores “a requirement for specific impairment” that was added in DSM IV.

Robert Spitzer says the motivation behind DSM III was simply “to have a classification system based on description rather than etiology.” Freudians were largely absent from the task force, he says, because psychoanalysts in the 1970s weren’t interested in diagnosis. He says Lane implies that “what we’ve done is medicalize shyness. But he never says at what point he would say it’s a disorder. What we ordinarily view as shyness is not a disorder. But when a child can’t talk to anybody, that’s a disorder. If somebody is so uncomfortable they can’t go to work, can’t have interpersonal relations, then it’s a disorder.”

Lane denies that he posed as “anything other than what I am.” He says his book is an intellectual history, that he approached the research with an open mind, and that the APA papers he got to study speak for themselves. He says Crews, a former Freudian, has an anti-Freudian ax to grind. And in spite of the DSM’s nominal requirement for impairment, he says, the manual’s “mixed message” led to an explosion of diagnoses—a 1994 estimate in the American Journal of Psychiatry, for instance, had one person in eight suffering from social phobia. “It’s not hysterical to be concerned about the overmedication of huge numbers of people, especially children, and about unknown long-term effects of SSRIs,” he says.

Public discussions about DSM V, which is expected by 2012, are now under way. The list of possible new ailments includes excessive shopping, overuse of the Internet, and apathy, and Lane predicts that if the book authenticates these “disorders,” the antishopping, antisurfing, and ennui-correction pills will soon follow.