Author: Christopher Lane

Unholy Influence: The Success Gospel of Norman Vincent Peale and Donald Trump

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Christopher Lane
Center for Bioethics and Medical Humanities
Northwestern University

Norman Vincent Peale, photo illustration

“Trust God, have faith, stick it out.” In the depths of the Great Depression, following years of financial worry and instability, these words by Norman Vincent Peale were a balm to millions of Americans. They offered hope and encouragement, paired belief in oneself with a sunnier future for all, and urged Americans to find religious solutions to individual and national problems.

From his pulpit in midtown Manhattan, with the aid of a vast publishing empire and media platform, Peale issued weekly reminders that well-being and piety were—or should be—inseparable. Belief in oneself was unlikely to endure, he warned, without fervent belief in God. Americans were newly encouraged to see themselves as living “under God,” just as Go to Church messages cropped up everywhere.

Peale’s success lay in binding the nation’s post-War boom to a heightened religiosity he had helped to orchestrate and was ardent in stoking. His most notorious acolyte, Donald Trump, stakes his appeal to voters on similar promises and assurances.

With a group of conservative allies in the early 1950s (among them President Dwight Eisenhower and FBI director J. Edgar Hoover, a trove of papers and letters confirms), Peale imbued such promises with stronger religious nationalism than ever before. The American Foundation of Religion and Psychiatry, Inc., the nationwide evangelical organization he cofounded in this same era, encouraged individuals, politicians, and corporations alike “to accept religiously motivated ideas and ideals as a means of solving problems.” Peale himself was clear about the consequences of pairing positive psychology with conservative populism and nationalism: “Emotion breeds enthusiasm, and enthusiasm is that which is necessary to Christian world conquest.”

Christ or Marx?

A surge in public religiosity, it was widely claimed at the time, would rejuvenate the nation and herald its return to preeminence. A mass “return to God” would also, Peale repeatedly asserted, strengthen the population by “inoculating” it against communism—which, because of communism in the USSR (Stalinism in particular), had been cited since the mid-1930s as a grave and worsening threat to the nation’s core beliefs.

For Peale, the question “Christ or Marx?” summed up a then “perilous” national dilemma. With “millions espousing [Marx’s] ideals with fanatical zeal,” he warned in October 1948, in a political sermon he titled “Democracy Is the Child of Religion,” freedom itself was threatened. Religious belief was, by contrast, “the best way to preserve” freedom and was, accordingly, the very principle on which America needed to “crusade.” The evangelical thrust was, for Peale, a consequence of standing united in steadfast opposition to forces such as collectivism. “Thus you have the issue,” he summed up: “Christ or Communism, Christ or chaos, Christ or catastrophe, Christ or the police state.”

As minister of one of the oldest churches in New York City, Peale was exceptionally well placed to air and promote such claims, to make being unreligious appear unbalanced, fanatical, and wholly “un-American.” He took on the task with relish, using his pulpit to lob almost weekly tirades at Washington.

With the national press riveted by his every move—much as his counterpart today looks to generate comparable media attention—Peale became a lightning rod for national conservative concerns, from the sale of liquor to the perceived threat of labor unions, the godless, and the “alien, un-American ideologies” that, in his view, were behind the threat.

A Gospel of Self-Assurance in an Age of Mass Anxiety

For those who know Peale from his most popular books, such as The Power of Positive Thinking, it can be disconcerting to realize how thoroughly politics imbued his early sermons, talks, and religious activities. Especially in the late 1930s and early 1940s, when Peale was burnishing his reputation as a minister and speaker not just in New York but nationwide, his crammed press folders report the activities and accusations of a man with an extraordinary appetite for political conflict.

During the Depression, Peale was especially active in hardline lobbying groups whose self-appointed mission was to question the New Deal’s very existence, to undermine it even by smearing its White House advocate, Franklin D. Roosevelt.

The president, notably, was targeted despite his own allusions to religious belief. Roosevelt’s first inaugural address was so “laden with references to Scripture” that it prompted the National Bible Press to release a chart highlighting the “Corresponding Biblical Quotations”; in his second inaugural address, in January 1937, Roosevelt also likened himself to “a modern-day Moses leading his people out of the wilderness.”

Peale was unpersuaded. One newspaper article, after declaring, “New Deal Assailed as Curb on Reform: Dr. Peale Charges Hasty Moves for Selfish Ends Impede Real Social Progress,” captures the flavor of his blunt attack: “Ill-Conceived Experimentation Makes Public Wary of Progress.”

In the New York Sun, Peale’s target shifted once again: “Peale Assails Class Conflict: Criticizes Methods Used by Roosevelt.” In this piece the New Deal was held virtually responsible for the mass inequality Congress had in fact passed it to redress. The message was unmistakable, and the New York American spelled it out: “Dr. Peale Asks America to Put Roosevelt Out. Country Must Change Him or Change Constitution, He Declares in Sermon.”

It was in alluding repeatedly to the President’s irregular church attendance that Peale found the political vulnerability that suited him as a minister. “Criticizes Roosevelt’s ‘Indifference to Religion,’” the Herald Tribune noted. “Dr. Peale Calls It Cause of Vital New Deal Errors.” Peale was particularly aggrieved by the president’s “Sabbath excursions and fishing trips,” though the relationship of these jaunts to seeming mistakes in the New Deal is still far from clear. President Roosevelt was, Peale said of a conflict over Supreme Court appointees, “a presumptuous seeker after improper power.” In yet another political sermon, he warned ominously of the government’s growing tendency to “autocracy” and the president’s tendency toward “dictatorship”: “We can pull him down when we wish.”

“We Can Pull Him Down When We Wish”

Anticommunism was to Peale and his allies a pro-Christian stance, even if the religious component was not strictly necessary for the critique to hold. Aware of Freud’s insights into the nature of religious enthusiasm (itself of vital importance to the experimental Religio-Psychiatric Clinic Peale had set up with his collaborator, the Christian psychiatrist Smiley Blanton, and to their later national organization, the American Foundation of Psychiatry and Religion, Inc.), Peale knew that fervor could fire up Americans beyond the pulpit, especially when packaged as a promise of national renewal through personal and religious redemption.

“It is increasingly evident,” he was quoted in the Herald Tribune as asserting, “that the only solution to the present [national and international] crisis is a deeper, more spiritual, more social Christianity.” Even more, he urged—in the kind of accusatory turn that made him popular among hardliners adopting the same refrain a decade later during the McCarthy hearings on un-American activities—“the man who shows no interest in Christianity and fails to support it is the real enemy of our social institutions.”

Although far from original, and rapidly adopted by other conservative revivalists, such as Billy Graham, Peale’s claims that faith in God, country, and self were broadly identical acquired importance by dint of their enormous influence and popularity in postwar America. By 1955, The Power of Positive Thinking had sold almost a million copies and was outselling all other books except the Bible. As his biographer Carol V. R. George concluded, “It was Peale’s message that gave definition to the religious revival” of the early 1950s.

Association with Far-Right Organizations

Peale’s association with such far-right organizations as the Committee for Constitutional Government, Spiritual Mobilization, the Christian Freedom Foundation—and, briefly, H. L. Hunt’s Facts Forum—sometimes generated enough controversy to be acutely embarrassing to him.

When a book on hardline conservatives appeared in 1943, noting accurately that Peale had shared a platform with Elizabeth Dilling and the Reverend Edward Lodge Curran, the damage to his reputation was considerable. Dilling, “a person the federal government ranked among the worst hate-mongers” was, notes George, “a ‘patriot’ who smeared liberals, Jews, African Americans, and other ethnic groups with the same broad brush.” Curran, founder of the National Committee for the Preservation of Americanism, was the author of alarmist books such as Spain in Arms: With Notes on Communism and Facts about Communism.

The Power of Religious Nationalism

After throwing his considerable weight behind Senator Joseph McCarthy on the need to expose “subversives” in the federal government, Peale broadcast his upbeat message in The Power of Positive Thinking. The runaway bestseller opened by urging the reader, “Believe in Yourself! Have faith in your abilities!” But Peale quickly pivoted to insisting, as he does in all his other writing, that the faith be religious in character. To maintain it, readers could try “prayer power,” which would aid the nation’s “spiritual mobilization.” The minister was part of a nationalist movement promising “freedom under God” and encouraging Americans to think of their elected representatives as providing nothing less than “government under God.”

By turns pep talk, sermon, and sales pitch, Peale’s book on positive thinking made reference to God ninety-one times, with forty-nine further allusions to the Bible. Originally titled The Power of Faith—and retitled, according to Peale, after some personal reluctance—the book devoted a large portion of its pages to evangelizing. Over and over, its author stressed, religious belief was a necessary condition for belief in oneself and the nation.

By repeatedly equating commercial acumen with piety, uncertainty with religious doubt, and personal and cultural failure with collectivism and godlessness, Peale and his admirers helped redefine religious Americans as socially superior winners (the “better people,” he once called them). By 1957, anything resembling “a low opinion of yourself” had come to seem anathema, “an affront to God” and, presumably, to self and country. Spotlighting the normally hidden underside to positive psychology, Peale warned the nation, “Never entertain a failure thought.” He would tell those prone to such thinking, “[Y]ou’re disintegrating. You’re deteriorating. You’re dying on the vine.”

Peale and Trump

After decades of attending Peale’s services, Trump named Peale and his writings among his strongest influences. Marble Collegiate Church has since disowned the former president, largely because of the excesses and untruths characterizing his 2016 campaign, but Peale’s influence persists in Trump’s careful tying of optimism and renewal with Christian nationalism.

One consequence of this Peale-like association is continued expansion of the equating of health and wealth with religious salvation. Another, directly related, is that failure and disappointment result from inadequate faith in oneself, God, and the nation. Just as Peale did in the 1950s, Trump declared in January 2016: “Christianity, it’s under siege.” Then, and since, the former president pledged to “protect” the religion as president. According to 2016 election data, white evangelicals voted for Trump by an 81-16 percent margin, mainline Protestants by 58-39.

White Evangelicals and Trump

Peale half-counseled, half-preached that religious faith was essential for the achievement of wealth and success. Trump’s broader or vaguer message is that national success and affluence appear “blessed,” religion (and, specifically, Christian nationalism) being the path to personal and national redemption. The unbelieving and the differently religious may wonder if they have any real presence in this vision of America. In his Union League speech in Philadelphia, Trump made a statement bearing equal parts promise and threat: “We will be one nation, under one God, saluting one flag.”

Once again on the campaign trail, this time facing 88 felony charges and four criminal trials, the now twice-impeached former president is again turning to religious nationalism and Peale’s efforts at binding belief in self with belief in God. According to yesterday’s New York Times, the former president has taken to “demanding new levels of devotion” from his followers by “infusing Christianity into his movement.” The final minutes of his political rallies are now given over to an “almost solemn, churchlike atmosphere,” in which the former president “gives a 10- to 15-minute sermon.”

The edition of the Bible that Trump began selling over Holy Week (during which he also compared himself to Jesus) is embossed with an American flag and the words “Holy Bible — God Bless the USA,” a pristine example of religious nationalism and an almost literal enactment of Sinclair Lewis’s famous warning, “When fascism comes to America, it will be wrapped in the flag and carrying a cross.”

[Adapted and updated from “The True Mission of Donald Trump’s Pastor,” The Daily Beast, Jan. 15, 2017, from Surge of Piety: Norman Vincent Peale and the Remaking of American Religious Life, Yale University Press, Nov. 2016.]

Among the topics the book illuminates:

— How anticommunism in the 1930s and 1940s was turned into a pro-Christian, pro-American stance.

— Why evangelical Americans today so often return to the cultural and political concerns that roiled the 1950s.

— How secularism was made to seem at odds with normalcy, with neutrality toward religion cast as a sign of weakness.

— How Freud’s ideas played an unintended role in promoting America’s religious revival.

— How organizations founded by Peale served as a bridge between the nation’s religious communities, its psychiatrists and psychologists, and its business and political leaders, bringing them all into closer alignment.

“In Surge of Piety, Christopher Lane ably shows the ways in which Norman Vincent Peale’s potent combination of Protestant Christianity, popular psychiatry and nationalist politics helped remake America.”—Kevin M. Kruse, author of One Nation Under God: How Corporate America Invented Christian America

“… reveals a surprisingly understudied dimension of Eisenhower’s political consensus: the religio-psychiatry of Norman Vincent Peale. Lane’s is a fascinating and accessible reassessment of a pivotal political moment, and the enduring fusion of popular religion and psychology in American life.”—Darren Dochuk, University of Notre Dame

“Enthralling … graceful and well-paced … requisite reading”—Mitch Horowitz, Washington Post

“… tells the story of Peale’s rise and fall crisply and without malice, even when Peale is at his more-huckster-than-minister gauchest”—Ray Olson, Booklist

 

How Shyness Was Pathologized: The Blending of Shyness with Social Anxiety Disorder

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Christopher Lane
Center for Bioethics and Medical Humanities
Northwestern University

Social Anxiety Disorder (SAD) was first defined as a type of mental illness in 1980, when the American Psychiatric Association published an influential, massively expanded third edition to its diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM-III for short).

Overbroad and Imprecise

At the time known as “Social Phobia,” a term many criticized as overbroad and imprecise (Cottle; Scott; Lane; Greenberg; Frances; Horwitz), the disorder joined more than a hundred newly created mental disorders, seven of them referencing anxiety alone.

Almost overnight, the new disorders vastly expanded a reference guide whose contents are daily invoked across the United States and much of the rest of the world, to authorize reimbursement for medical and clinical treatment. To much fanfare, the new disorders were widely touted as “evidence-based” and as “watertight,” amid a growing chorus of interest in “precision medicine” that could provide targeted treatment.

Loosened Criteria, More Diagnosis

The disorder was given its current name in 1987, when the APA brought out a revised 3rd edition with more than a dozen new disorders, on top of those it had first introduced in 1980, bringing the total to 112 new psychiatric conditions for which drugs could be prescribed.

In addition to giving the condition a more “user-friendly” name, the revised edition (DSM-IIIR) greatly expanded its criteria and removed one of its most-important brakes—that those with the condition needed to exhibit “a compelling desire to avoid” fear-inducing situations. After 1987, they had only to show “marked distress” for the diagnosis to be considered valid and reimbursable, for what quickly became mostly drug-related treatment (APA 1987:241).

By the time the APA brought out a 4th edition of its diagnostic manual 7 years later still, in 1994—an edition that would sell more than a million copies—recognition of the stark level of overlap between SAD and shyness led the APA to issue a warning—one that Allen Frances, Chair of the DSM-IV Task Force, later claimed few noticed or heeded—urging clinicians not to confuse the disorder with the personality trait. “Performance anxiety, stage fright, and shyness in social situations that involve unfamiliar people are common,” DSM-IV stressed, “and should not be diagnosed [as Social Anxiety Disorder] unless the anxiety or avoidance leads to clinically significant impairment or marked distress” (APA 1994:455).

“Embarrassment May Occur”

“The essential feature” of Social Anxiety Disorder, the text-revised edition of the DSM-IV announced, in one of its loosest definitions yet, “is a marked and persistent fear of social or performance situations in which embarrassment may occur… The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing” (APA 2000:450; my emphases). Examples include fear of eating and writing in public, concern about hand-trembling, avoidance of public restrooms, and “excessive fear of public speaking” (453).

However, because public-speaking anxiety is widespread and self-reported shyness, according to two Stanford psychologists, involves “nearly 50% (48.7% +/- 2%)” of North Americans (Henderson and Zimbardo), with percentages that replicate closely worldwide, critics have called the degree of overlap between SAD and shyness worrying and egregious (Cottle; Scott; Lane). They note that the DSM has over the years added routine fears that have the unavoidable effect of lowering the disorder’s diagnostic thresholds, making it too easy to be diagnosed, despite the APA’s 1994 warning about the outcome. In Saving Normal (2013), in a kind of mea culpa about now-“out-of-control psychiatric diagnosis,” though with less about his own role in loosening them, DSM-IV Chair Frances titled a relative section of the book “Social Phobia Makes Shyness an Illness” (152-53).

Given this multiyear emphasis on lowering diagnostic thresholds to make ever-larger numbers of people diagnosable, successive editions of the DSM have greatly increased—that is, artificially inflated—prevalence rates and, with them, the risk of misdiagnosis among those with mild-to-serious shyness, as with many other cognate conditions. Signs of “marked distress” in SAD, according to the manual, now include concern about saying the wrong thing—a fear afflicting almost everyone on the planet.

While the DSM indicates that for SAD to be diagnosed the subject must “recognize that the fear is excessive or unreasonable,” Henderson and Zimbardo note from robust data that shyness is similarly “defined experientially as discomfort and/or inhibition in interpersonal situations, in ways that interfere with pursuing one’s interpersonal or professional goals.” Accordingly, they put shyness on a spectrum that ranges “from mild social awkwardness to totally inhibiting social phobia,” arguing that it can, like SAD, “be chronic and dispositional.”

Much in Common, Tough to Disentangle

As such, shyness and SAD have much in common and may in nonextreme cases be difficult to distinguish. As University of Pittsburgh psychiatrist Samuel M. Turner and colleagues noted in Behaviour Research and Therapy, “The central elements of social phobia, that is discomfort and anxiety in social situations and the associated behavioral responses . . . are also present in persons who are shy” (Turner 1990:497; my emphasis). Hence the concern of DSM-IV that practitioners would confuse the two, in effect medicalizing a behavioral trait whose numbers can affect almost half of any human population.

According to Mary H. McCaulley and colleagues at Gaineville’s Center for Applications of Psychological Type, from an 8-year study of 75,000 cases, the percentage of shyness and introversion among 11th- and 12th-grade Americans was 37 for boys and 31 for girls. At older ages, the Center determined, similarly adopting the Myers-Briggs Type Indicator, the trait increased dramatically to affect 51 percent of boys and 43 percent of girls. Thereafter, including at graduate school, the numbers remained virtually unchanged, with 50 percent of men and 48 percent of women self-defining as shy or/and introverted (McCaulley, in Lane 2007:83).

Elastic Properties, Expanded Prevalence

Since shyness is widespread, situational, yet varies greatly in intensity and impairment, the prevalence rates for Social Anxiety Disorder have, unsurprisingly, proven highly elastic and depend heavily, as DSM-IV-TR puts it, “on the threshold used to determine distress or impairment and the number of types of social situations specifically surveyed” (APA 2000:453). “Epidemiological and community-based studies,” the manual continues, “have reported a lifetime prevalence of Social Phobia ranging from 3% to 13%… In one study, 20% reported excessive fear of public speaking and performance, but only about 2% appeared to experience enough impairment or distress to warrant a diagnosis of Social Phobia.”

Similar results were reported in 1994 when Murray Stein, a specialist in anxiety at the University of California at San Diego, and his team published an influential article about the disorder, “Setting Diagnostic Thresholds for Social Phobia: Considerations from a Community Survey of Social Anxiety.” The article drew from a single study—a random telephone survey of 526 urban Canadians—with results suggesting that social anxiety among them ranged from 1.9 percent to 18.7 percent, depending on the diagnostic threshold used (Stein 1994:412). That is, the problem affected either less than two in every hundred or almost one person in five.

Diagnostic Imprecision, Rampant Misdiagnoses

This brief history of SAD as a psychiatric disorder suggests that confusion about the condition’s prevalence and diagnostic threshold has plagued psychiatry and its patients since the edition’s vast expansion in 1980, while playing a substantial role in raising its medical profile. In 1993, just thirteen years after the disorder was formally approved, Psychology Today called it “the disorder of the decade” (“Disorder” 1993:22). By December 2000, the Harvard Review of Psychiatry was representing SAD as the third most-common mental disorder in the U.S, behind only depression and alcoholism (Rettew 2000:285). According to the 1994 National Comorbidity Survey, using DSM-IV criteria, as much as 12.1 percent of the U.S. population might have SAD and 28.8 percent—almost one in three—suffer from some kind of anxiety disorder (Kessler 2005:593).

Marketing SAD: “Is she just shy? Or is it …?”

Throughout these years, with almost synchronized adjustment, marketing campaigns for pharmaceutical treatments of SAD took an already hazy distinction and blurred it even further, repeatedly muddying the line between the condition and shyness—that is, if you take the DSM seriously, between pathology and normalcy. One ad appearing in the American Journal of Psychiatry featured a young woman with downcast eyes and text that asked, “Is she just shy? Or is it Social Anxiety Disorder?” (reproduced in Lane 2007:138).

The product director for Paxil—the first antidepressant given an FDA license for SAD—volunteered to an interviewer: “Every marketer’s dream is to find an unidentified or unknown market and to develop it. That’s what we were able to do with social anxiety disorder.” The quotation appears in a 2001 Washington Post article entitled “Drug Ads Hyping Anxiety Make Some Uneasy” (Vedantam 2001).

GlaxoSmithKline, Paxil’s manufacturer, went on to put more than $92 million behind a campaign aimed at convincing people that their shyness might in fact be a disorder treatable with drugs. The campaign was called “Imagine Being Allergic to People,” and it ran on bus shelters across the U.S. One poster featured a young man in an American diner staring forlornly into a coffee-cup (reproduced in Lane 2007:124).

“Freezing, Shrinking, or Failing to Speak in Social Situations”

Psychiatric literature on SAD has both noted and reproduced its broadly elastic properties. For instance, John R. Marshall’s Social Phobia: From Shyness to Stage Fright defines the disorder in its most expansive way (as his subtitle illustrates), emphasizing the role of common fears and concerns, including public speaking, and dealing with authority figures, social gatherings, and other forms of largely job-related embarrassment. Although Marshall acknowledges in his book, “There is no absolute score that indicates social phobia,” he includes diagnostic tests that invite readers to assess themselves, based on their fear and avoidance of “being criticized” and “being embarrassed and humiliated,” psychological states involving much-lower thresholds. “Patients in a treatment study for social phobia,” he adds, “had pretreatment scores … ranging from 19 to 56” (Marshall 1994:171-73).

The psychiatric literature on SAD is vast, tied to a host of drug trials and clinical studies aimed loosely at lessening suffering. Chronic anxiety can be a serious problem needing psychological and other kinds of treatment (for example, CBT, psychodynamic therapy, and, for situational anxiety, beta-blockers).

Nevertheless, a clear risk remains that by calling social anxiety a mental disorder and by drastically lowering its diagnostic thresholds to include such routine fears as public-speaking anxiety, the DSM has made an important distinction between ordinary shyness and SAD hazy and ambiguous. As Frances concedes, “Social Phobia Makes Shyness an Illness.”

With the most-recent (2022) text revised edition of DSM-5 stating that “in children, the fear or anxiety [indicating Social Anxiety Disorder] may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations,” leaving the criteria even-more routine and everyday, its audience still-more captive, in the sense that children can’t easily refute their diagnostic markers, the overlap between shyness and SAD is certain to stay controversial for years to come.

  

REFERENCES & FURTHER READING

Burstein, M, L. Ameli-Grillon, and K. Merikangas. 2011. “Shyness versus Social Phobia in US Youth.” Pediatrics 128.5:917-25.

Cottle, M. (Aug. 2, 1999) “Selling Shyness: How Doctors and Drug Companies Created the ‘Social Phobia’ Epidemic.” New Republic. 24-29.

Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. (1980) American Psychiatric Association, Washington, D.C.

Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition Revised. (1987) American Psychiatric Association, Washington, D.C.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. (1994) American Psychiatric Association, Washington, D.C.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revised. (2000) American Psychiatric Association, Washington, D.C.

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition Text Revised. (2022) American Psychiatric Association, Washington, D.C.

“Disorder of the Decade.” (July-Aug. 1993) Psychology Today 26.4:22.

Frances, A. (2013) Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. William Morrow, New York.

Greenberg, G. (2013) The Book of Woe: The DSM and the Unmaking of Psychiatry. Blue Rider, New York.

Henderson, L, and P. Zimbardo (in press) “Shyness.” Encyclopedia of Mental Health. Academic Press, San Diego.

Horwitz, A.V. (2021) DSM: A History of Psychiatry’s Bible. Johns Hopkins University Press, Baltimore.

Kessler, R. C., P. Berglund, O. Demler, R. Jin, and E. Walters. (2005) “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication.” Archives of General Psychiatry 62.6:593-602.

Lane, C. (2007) Shyness: How Normal Behavior Became a Sickness. Yale University Press, New Haven.

Marshall, J. R., with S. Lipsett. (1994) Social Phobia: From Shyness to Stage Fright. Basic Books, New York.

Rettew, D. R. (2000) “Avoidant Personality Disorder, Generalized Social Phobia, and Shyness: Putting the Personality Back into Personality Disorders.” Harvard Review of Psychiatry 8.6:283-97.

Scott, S. (2006) “The Medicalisation of Shyness: From Social Misfits to Social Fitness.” Sociology of Health and Illness 28.2:133-53.

Stein, M. B., J. R. Walker, and D. R. Forde. (1994) “Setting Diagnostic Thresholds for Social Phobia: Considerations from a Community Survey of Social Anxiety.” American Journal of Psychiatry 151.3:408-12.

Turner, S. M., D. C. Beidel, and R. M. Townsley. (1990) “Social Phobia: Relationship to Shyness.” Behaviour Research and Therapy 28.6:497-505.

Vedantam, S. (July 16, 2001) “Drug Ads Hyping Anxiety Make Some Uneasy.” Washington Post.

[Updated and revised extensively from Lane, C., “Shyness and Social Anxiety,” in The Wiley-Blackwell Encyclopedia of Health, Illness, Behavior, and Society (2013), ed. W.C. Cockerham, R. Dingwall, and S. Quah, Wiley-Blackwell, Hoboken, NJ.]

Bitterness touted as sanctioned mental disorder

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By Sharon Kirkey, Canwest News Service

May 31, 2009  5:20 PM

Bitterness should be classified an official brain illness, according to psychiatrists who say people who experience prolonged bitterness over a breakup or conflict at work are “ill” and need treatment.

Bitterness should be classified an official brain illness, according to psychiatrists who say people who experience prolonged bitterness over a breakup or conflict at work are “ill” and need treatment.

They are proposing that “post traumatic embitterment disorder” be included in the Diagnostic and Statistical Manual of Mental Disorders, psychiatry’s official catalogue of mental dysfunction.

Now in its fourth edition, DSM is undergoing its first major revision since 1994. DSM-V is due to be published in 2012, and other possible new contenders for inclusion include Internet addiction disorder, apathy disorder, compulsive buying disorder, compulsive pathological overeating, hoarding, “premenstrual dysphoric disorder” and “partner relational problem” ­ “a pattern of interaction between spouses or partners characterized by negative communication (criticisms, for example), distorted communications (such as unrealistic expectations) or non-communication (withdrawal).”

Working groups composed of more than 120 scientific researchers and clinicians are drafting diagnostic criteria for mood disorders, anxiety disorders, personality disorders and psychoses. They’re deciding which disorders should be included, revised or removed. Field tests of new diagnostic criteria are due to begin this summer.

With each revision comes new disorders. The manual ­ as influential in Canada as it is worldwide ­ listed 112 disorders when first published in 1952. The most recent issue contains 374, and runs 886 pages.

As the number of diagnoses grows, so too does the chorus from critics that the book pathologizes behaviour that’s within the normal spectrum.

Post-traumatic embitterment disorder is described as a pathological reaction to a single, negative life event, such as conflict at work, unemployment, divorce, illness or separation. People view the event as unjust, a violation of their basic beliefs and values, and “want the world to see how badly they have been treated,” according to published studies.

“People feel wronged, humiliated and that some injustice has been done to them,” says Dr. Michael Linden, the German psychiatrist who named the behaviour after reporting an increase in affected patients in the wake of German reunification.

“The critical part is this lasting and very intensive emotional embitterment, a mixture of depression and helplessness and hopelessness . . . It’s a very nasty emotion.”

People have intrusive thoughts and memories about the event, and get locked into a serious mental state, he says. “These people don’t have the feeling that they must change, but rather have the idea that the world should change or the oppressor should change, so they don’t ask for treatment.”

Ten years of research suggests it affects one to two per cent of the population, but Linden says the incidence rises during times of societal change ­ including economic upheaval. “We are all vulnerable in those areas which are especially important to us. So, if you really think your job is the centre of your life, that’s where you’re vulnerable.”

He says adding severe embitterment to the manual of mental illness could help patients get help and encourage research into the disorder.

But some critics question just how doctors could distinguish between irrational and reasonable bitterness.

Christopher Lane, a professor of literature at Northwestern University and author of Shyness: How Normal Behavior Becomes a Sickness, says it’s one thing to try to reach “that fraction of the profoundly disaffected which snaps suddenly and commits desperate crimes as a result.”

But Lane says embitteredness overlaps with other disorders in the DSM, including “intermittent explosive disorder,” and that adding a separate DSM code for it would make it “almost impossible to distinguish the acutely stressed from the vast majority of the population that bears grudges or is simply justifiably angry about the current state of the country.”

In his blog for Psychology Today, Lane writes: “Imagine, if you will, the inevitable ads: ‘Think it’s just bitterness from job loss, foreclosure on your home, or that nonexistent pension for which you’ve been saving all your working years? It may be post-traumatic embitterment disorder, a mental illness that some doctors think is due to a chemical imbalance . . .’ ”

The disorder could be added to the appendix of the next edition of DSM as a sickness worthy of further study, joining such others as caffeine withdrawal and premenstrual dysphoric disorder, or PMDD. The guidebook says a woman may be experiencing PMDD if she has five out of 11 symptoms that include anxiety, feeling “keyed up” or “on edge.” Some experts are now advocating PMDD be formally classified a mental disorder.

“There’s a sizable amount of literature pushing back against it, saying there is astonishingly flimsy evidence for this and that it’s a catastrophic mistake to represent it as a form of depression,” Lane said in an interview.

Apathy disorder also has been suggested for inclusion in the DMS. Experts have argued apathy can occur alone, or in conjunction with such other conditions as Huntington’s disease, Alzheimer’s, Parkinson’s and stroke. It is also a side-effect of antidepressants, sedatives and other psychotropic drugs.

“The obvious situation there would be to scale back the number of psychotropics people are taking, not to pathologize the side-effects from those drugs,” Lane says.

Adding apathy disorder to the psychiatry manual’s mental problems would introduce “the everyday vernacular sense of being indolent or lazy,” he says.

Relational disorder risks being so open-ended and broadly defined that almost every relationship could theoretically fall under it. “It could become simply a pattern of failed relationships owing to disturbances in the brain,” says Lane.

Task force and work group members have had to sign confidentiality agreements prohibiting them from divulging confidential information about the revision process. “The secrecy makes the scenario imaginable that (relational disorders) could simply appear in 2012 with a set of symptoms that would be mind-bogglingly expansive,” Lane says.

skirkey@canwest.com
© Copyright (c) Canwest News Service

Maladies à vendre [Diseases for Sale]

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jeudi 5 mars 2009, par Laurent Lemire

Le londonien Christopher Lane est une personnalité du milieu des sciences humaines aux Etats-Unis. Professeur de littérature à la Northwestern University de Chicago, spécialiste de l’histoire intellectuelle aux XIXe et XXe siècles, il bouscule souvent le conformisme universitaire. Cette fois, il est allé enquêter du côté des laboratoires pharmaceutiques, des agences de pub et de l’administration pour expliquer comment la société invente des maladies pour vendre des médicaments. Résultat, son brillant essai sur la manière dont l’introverti s’est vu requalifié en psychotique léger s’est installé dans les meilleures ventes pendant neuf fois en 2007 et 2008.

Dans cette enquête menée tambour battant qui paraît ces jours-ci chez Flammarion [1], il raconte comment des commissions, derrière des portes closes, ont réussi en six ans à transformer un trait de caractère – la timidité – en pathologie après d’épiques batailles de diagnostics. Mais Christopher Lane nous propose aussi de réfléchir sur cette curieuse volonté de soigner « l’anxiété sociale » et sur l’idée même de normalité dans nos sociétés aseptisées.

Entretien

L’@mateur d’idées – Vous expliquez très bien comment l’anxiété est devenue une maladie. Mais pourquoi l’est-elle devenue ?

Christopher Lane – En premier lieu, parce que l’Association américaine de psychiatrie (American Psychiatric Association, APA) a ajouté en 1980 la « phobie sociale » à la liste des nouvelles maladies mentales avec des symptômes comme « la peur de manger seul dans un restaurant » ou « la peur de parler en public » ce qui relève exactement de la timidité. Les sociétés de communication et de publicité ont ensuite propagé cette idée dans les médias et les laboratoires pharmaceutiques ont cherché à convaincre le grand public qu’il fallait faire face à une « épidémie de timidité ». C’est ainsi qu’en 1993, le magazine Psychology Today (« Psychologie aujourd’hui ») a qualifié la « phobie sociale » de « trouble de la décennie ». En regardant ce qui s’est passé, je suis étonné de voir comment une si petite preuve scientifique a permis de créer une nouvelle maladie tout en restant imperméable à la véritable tragédie que cela pouvait avoir sur les gens.

Dans un deuxième temps, on comprend que l’APA voulait supprimer la « névrose d’angoisse » de son manuel de diagnostic, parce que le terme de névrose était trop connoté à la psychanalyse et apparemment pas assez scientifique pour elle. Mais son propre procédé relève plus de l’hypothèse que de la science. Après avoir décidé que l’inquiétude était en fait un désordre mental, L’APA a été obligé de redéfinir – en fait à réinventer – tous les aspects de cette inquiétude, y compris sous ses formes relativement légères, en leur donnant des termes psychiatriques. Ainsi, par exemple, elle a créé le désordre de panique, le trouble anxieux généralisé, et la phobie sociale. C’est ainsi que des millions d’Américains, d’Européens, et d’Asiatiques ont pris des médicaments uniquement parce qu’un comité s’était réuni vers la fin des années 70 et que plusieurs psychiatres ont réussi à faire adopter leurs hypothèses comme de nouveaux désordres mentaux. J’ai passé en revue leur correspondance, leurs rapports et souvent leurs débats et je suis obligé de constater que leur justification est aussi mince qu’ inquiétante.

L’@mi – Comment la timidité a-t-elle été perçue avant notre époque moderne ? Était-elle mal ou bien vue ?

C.L. – Pendant les trois dernières décennies, la timidité a été perçue comme une forme fortement fragilisante et cause de grande angoisse et souvent d’accablement. Aux XIX e et XX e siècle, dans l’ensemble, la timidité était assimilée à la modestie, à l’introspection et elle était le plus souvent vue comme un trait de caractère sans importance, voire positif. Aujourd’hui, il est certain que la moitié de ces personnes se définiraient comme timides. C’est infiniment banal de voir les gens décrire leur personnalité désormais. Pourtant, il est intéressant de rappeler qu’avant le XVII e siècle, le mot ne s’appliquait qu’aux animaux – les chevaux, par exemple, étaient ombrageux – et que pendant longtemps, même lorsqu’il s’appliquait aux hommes, il n’a été utilisé que pour décrire des groupes et même des communautés entières jugés discrètes ou retirées. Ainsi, l’idée que la timidité a une dimension pathologique chez l’individu est très récente en effet.

L’@mi – Quelle a été l’importance des laboratoires pharmaceutiques dans ce processus ?

C.L. – Les entreprises pharmaceutiques ont commencé à jouer un rôle significatif vers la fin des années 50 et au début des années 60, quand ils ont commencé à lancer des antidépresseurs et d’autres médicaments psychotropes pour la consommation individuelle plutôt que, comme par le passé, pour de grands hôpitaux psychiatriques gérés par l’Etat. Le Collegium Internationale Neuropsychopharmacologium (CINP) a été formé dans les années 50 et ses premiers congrès ont été organisés par de grandes maisons de l’industrie pharmaceutiques comme Roche, Sandoz et Rhône-Poulenc. Aux Etats-Unis depuis 1997, les entreprises pharmaceutiques ont concentré leurs énormes ressources financières au développement de ces marchés auprès des consommateurs et ils ont dépensé pour cela près de 3 milliards de dollars (2,37 milliards d’euros) chaque année en publicité. La campagne pour la timidité disait : « Et si vous étiez allergique aux gens ? ». Pour le Deroxat, le médicament prescrit dans cette campagne, il en a coûté à GlaxoSmithKline 92,1 millions de dollars (72,7 millions d’euros) en publicité et promotion pour l’année 2000, soit 3 millions de dollars de plus que pour ce qui a été dépensé en faveur du Viagra.

« Et si vous étiez allergique aux gens ? »

L’@mi – Tous les psychiatres américains acceptent-ils le Manuel de Diagnostic de l’APA ?

C.L. – En fait aucun ne l’ accepte. La plupart d’entre eux constatent que le Manuel de Diagnostic pose plus de problèmes qu’il n’en résout, qu’il est peu fiable, contradictoire et envisage des maladies qui n’en sont pas. Mais puisque ce Manuel a été crédité d’une telle autorité par un grand nombre de psychiatres réputés, qu’il est reconnu par les compagnies d’assurance maladie, les tribunaux, les prisons, les écoles et la plupart des professionnels de la santé aux Etats-Unis, ce désaccord est insignifiant et n’entame en rien son prestige. Récemment, tout de même, les médias américains ont commencé à s’intéresser à l’histoire de ce Manuel, à son contenu et se sont posé des questions à son sujet. Mais nous avons encore beaucoup de chemin à faire avant que l’APA accepte, par exemple, d’effacer des douzaines de maladies douteuses.

L’@mi – Qu’est-ce cela signifie pour notre société moderne ?

C.L. – Cela souligne surtout la puissance incroyable que nous avons accordée à des organismes comme l’APA pour décider du nombre de maladies psychiatriques et comment elles devaient être traitées. Cela s’explique en grand partie en raison des milliards de dollars dépensés chaque année par l’industrie pharmaceutique en publicité pour faire croire aux Américains et aux Européens que la solution à leurs angoisses ou à leurs problèmes quotidiens se trouve dans la médecine, sous la forme de pilules. Nous regardons hors de nous-mêmes pour trouver la solution à nos souffrances et à nos malheurs, souvent parce qu’il est plus simple de croire que nous pouvons trouver un remède chimique plutôt qu’adopter un changement de vie. Je pense que cela à profondément changé notre compréhension de la normalité. À cause de l’APA, de moins en moins de gens peuvent se considérer comme normaux sans avoir besoin d’une aide médicale ou psychiatrique.

L’@mi – Cette attitude représente-elle un danger pour la société ?

C.L. – Aux États-Unis, plus de 67,5 millions de personnes – soit un quart de la population – ont suivi un traitement d’antidépresseurs. Aujourd’hui nous commençons seulement à saisir les effets secondaires de ces drogues à court terme comme le risque d’attaque, de crise cardiaque, d’insuffisance rénale ou d’anomalies congénitale lorsque le traitement est pris pendant la grossesse. Pour le long terme, nous ne disposons pas encore de données sur plusieurs générations tout simplement parce qu’elles n’ont pas encore été étudiées. Je trouve cela franchement alarmant.

Les entreprises pharmaceutiques augmentent la recherche sur leurs produits, mais les échecs ne sont jamais communiqués, ce qui donne l’impression que toutes ces drogues son efficaces. Plutôt que de se sentir concernés par ce qu’ils ignorent sur ces substances, des psychiatres influents aux Etats-Unis continuent de les prescrire massivement aux adolescents et aux jeunes enfants, en déclarant même que bien plus de gens devraient en prendre.

Ils publient dans les grands journaux psychiatriques des déclarations qui proclament « Environ la moitié des Américains remplissent les critères de définition d’un trouble répertorié au DSM-IV », ce qui signifie que la moitié du pays peut-être décrite comme mentalement malade. Ceci aurait pu relever de la science-fiction, mais cela relève maintenant de réalité sociale. Les psychiatres en question ne disent jamais, « vous savez, si nous considérons la moitié du pays comme mentalement malade c’est peut-être que notre Manuel de Diagnostic est douteux, notre pensée fausse, notre recherche imparfaite et nos arguments exagérés. »

Au lieu de cela, ils insistent pour que l’apathie, l’achat compulsif, le « syndrome parental d’aliénation » et l’abus d’internet soient inscrits dans la prochaine édition du Manuel de Diagnostic en 2012. Je pense que de tels dangers parlent d’eux-mêmes.

[1] Comment la psychiatrie et l’industrie pharmaceutique ont médicalisé nos émotions de Christopher Lane, traduit dans l’anglais par François Boisivon, Flammarion, coll. « Bibliothèque des savoirs », 370 p., 26 €.

Enfermedades en venta [Diseases for Sale]

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[link]

 

El londinense Christopher Lane es una personalidad del campo de las ciencias humanas en los Estados Unidos. Profesor de literatura en la Universidad Northwestern de Chicago, especializado en la historia intelectual en los siglos XIX y XX, sacude a menudo el conformismo universitario. Esta vez ha investigado por el lado de los laboratorios farmacéuticos, de las agencias de publicidad y de la administración para explicar cómo la sociedad inventa enfermedades para vender medicamentos. Resultado: su brillante ensayo sobre la manera según la cual el introvertido ha sido recalificado en psicótico (…) se ha instalado entre las mejores ventas durante nueve meses en 2007.En esta investigación que aparece estos días en (la editorial) Flammarion, cuenta cómo las comisiones, tras sus puertas cerradas, han conseguido transformar en seis años un rasgo de carácter —la timidez—en patología, tras épicas batallas de diagnósticos. Pero Christopher Lane nos propone también reflexionar acerca de esta curiosa voluntad de cuidar (soigner) la angustia social (anxieté sociale) y también acerca de la idea misma de normalidad en nuestras sociedades asépticas.

Entrevista

L’Amateur d’idées: Usted explica muy bien cómo la ansiedad se ha convertido en una enfermedad. ¿Por qué ha sido así?

Christopher Lane: En primer lugar, porque la Asociación Americana de Psiquiatría (APA) ha añadido en 1980 la “fobia social” a la lista de nuevas enfermedades mentales con síntomas como “el miedo a comer solo en un restaurante” o “el miedo a hablar en público”, lo que viene a ser exactamente la timidez. Las sociedades de comunicación y de publicidad han propagado después esta idea en los medios y los laboratorios farmacéuticos han intentado convencer al gran público de que era preciso hacer frente a una “epidmia de timidez”. Es así que, en 1993, la publicación Psychology Today ha calificado a la fobia social de “trastorno del decenio”. Mirando lo que ha pasado, me asombra ver cómo una tan pequeña prueba científica ha permitido crear una nueva enfermedad, permaneciendo a la vez impermeable a la verdadera tragedia que podía suponer sobre la gente.

En un segundo tiempo, se comprende que la APA quería suprimir la “neurosis de angustia” de su manual diagnóstico, porque el término de neurosis estaba demasiado connotado al psicoanálisis y no era aparentemente lo suficientemente científico para ella. Pero su propio modo de proceder entraña más de hipótesis que de ciencia. Después de haber decidido que la inquietud era un desorden mental, la APA se ha visto obligada a redefinir –de hecho, a reinventar- todos los aspectos de esta inquietud, incluso bajo sus formas relativamente ligeras, otorgándoles términos psiquiátricos.

De esta manera, por ejemplo, ha creado el desorden de pánico, el trastorno por ansiedad generalizada, y la fobia social. Resultando que millones de americanos, europeos y asiáticos han tomado medicamentos únicamente porque un comité se ha reunido hacia el final de los años setenta y algunos psiquiatras han logrado hacer adoptar sus hipótesis como nuevos trastornos mentales. He revisado su correspondencia, sus relaciones y a menudo sus debates y estoy obligado a constatar que su justificación es tan débil como inquietante.

L’ami: ¿Cómo ha sido percibida la timidez antes de nuestra época moderna? ¿Ha sido mal o bien vista?

C.L.: Durante los tres últimos decenios, la timidez ha sido percibida como una forma fuertemente fragilizante y causa de gran angustia y a menudo de abatimiento. En los siglos XIX y XX, en general, la timidez ha sido asimilada a la modestia, a la introspección, y era vista a menudo como un rasgo de carácter sin importancia, hasta positivo. Hoy, es cierto que la mitad de estas personas se definirían como tímidas. Es infinitamente banal ver a las personas definir su personalidad a partir de ese momento. Sin embargo, es interesante recordar que antes del siglo XVII, la palabra no se aplicaba más que a los animales (los caballos, por ejemplo, eran desconfiados), y que durante largo tiempo, incluso cuando se aplicaba a los hombres, no se utilizaba más que para describir grupos e incluso comunidades enteras juzgadas discretas o retiradas. De tal modo que la idea de que la timidez tiene una dimensión patológica en el individuo es, en efecto, muy reciente.

L’Ami: ¿Cuál ha sido la importancia de los laboratorios terapéuticos en este proceso?

C.L.: Las empresas farmacéuticas han comenzado a jugar un rol significativo desde el fin de los años 50 y comienzo de los años 60, cuando empezaron a lanzar antidepresivos y otros psicótropos para el consumo individual y no, como ocurría en el pasado, para los grandes hospitales psiquiátricos administrados por el estado. El Collegium Internationale Neuropsychopharmacologium (CINP) se constituyó en los años 50 y sus primeros congresos fueron organizados por las grandes casas de la industria farmacéutica como Roche, Sandoz y Rhone-Poulenc. En los Estados Unidos, desde 1997, las empresas farmacéuticas han concentrado sus enormes recursos financieros en el desarrollo de estos mercados de consumidores y han gastado para ello cerca de 2.370 millones de euros cada año en publicidad. La campaña para la timidez decía: “Y si usted fuera alérgico a la gente?” Para el Deroxat, el medicamento prescrito en esta campaña, le ha costado a GlaxoSmithKline 72,7 millones de euros en publicidad y promoción en el año 2000, o sea 3 millones de dólares más que lo que se gastó a favor del Viagra.

L’Ami: ¿Todos los psiquiatras americanos aceptan el Manual Diagnóstico de la APA?

C.L.: De hecho nadie lo acepta. La mayor parte de ellos constatan que el Manual Diagnóstico plantea más problemas que los que resuelve, que es poco fiable, contradictorio, y que apunta a enfermedades que no son tales. Pero dado que este Manual ha sido acreditado de tal autoridad por una gran número de reputados psiquiatras, que está reconocido por las compañías de seguros médicos, los tribunales, las prisiones, las escuelas y la mayor parte de los profesionales de la salud en los Estados Unidos, este desacuerdo es insignificante y no empaña en nada su prestigio. Recientemente, los medios americanos han empezado a interesarse por la historia de este Manual, su contenido y se han planteado preguntas al respecto. Pero tenemos aún mucho camino por hacer antes de que la APA acepte, por ejemplo, borrar docenas de enfermedades dudosas.

L’Ami: ¿Qué significa esto para nuestra sociedad moderna?

C.L.: Subraya sobre todo la potencia increíble que hemos concedido a organismos como la APA para decidir acerca del número de enfermedades psiquiátricas y de cómo deben ser tratadas. Esto se explica en gran parte en razón de los miles de millones de dólares gastados cada año por la industria farmacéutica en publicidad para hacer creer a los americanos y a los europeos que la solución a sus angustias o a sus problemas cotidianos se encuentra en la medicina, bajo la forma de píldoras. Miramos fuera de nosotros mismos para encontrar la solución a nuestros sufrimientos y a nuestras desgracias, a menudo porque es más simple creer que podemos encontrar un remedio químico antes que adoptar un cambio de vida. Pienso que esto ha cambiado profundamente nuestra comprensión de la normalidad. A causa de la APA, cada vez son menos las personas que pueden considerarse como normales sin tener necesidad de ayuda médica o psiquiátrica.

L’Ami: ¿Esta actitud representa un peligro para la sociedad?

C.L.: En los Estados Unidos, más de 67,5 millones de personas, o sea un cuarto de la población, ha seguido un tratamiento con antidepresivos. Es ahora solamente cuando empezamos a comprender los efectos secundarios de estas drogas a corto plazo, como el riesgo de ataque, de crisis cardíaca, de insuficiencia renal o de anomalías congénitas cuando el tratamiento se produce durante el embarazo. A largo plazo no disponemos aún de datos sobre diversas generaciones, simplemente porque no han sido estudiados todavía. Encuentro esto francamente alarmante. Las empresas farmacéuticas aumentan la investigación sobre sus productos, pero los fracasos nunca son comunicados, lo que da la impresión de que todas estas drogas son eficaces. En lugar de preocuparse por lo que ignoran de estas substancias, algunos psiquiatras influyentes en Estados Unidos continúan prescribiéndolos masivamente a los adolescentes y a los jóvenes enfermos, declarando incluso que bastante más gente lo deberían tomar. Publican en las grandes publicaciones psiquiátricas declaraciones que proclaman “Cerca de la mitad de los americanos cumplen los criterios de definición de un trastorno del DSM-IV”, lo que significa que la mitad de la población puede ser descrita como mentalmente enferma. Esto podría parecernos de ciencia ficción, pero expresa la realidad social actual. Los psiquiatras en cuestión no dicen nunca: “Mire, si nosotros consideramos la mitad del país como mentalmente enferma es tal vez que nuestro Manual de Diagnóstico es dudoso, nuestro pensamiento falso, nuestra investigación imperfecta y nuestros argumentos exagerados”. En lugar de esto, insisten para que la apatía, la compra compulsiva, el síndrome de alienación parental y el abuso de Internet sean inscritos en la próxima edición del Manual Diagnóstico en 2012.

Traducción: Juan del Pozo

Intervention de Christopher Lane pour la cérémonie de remise du Prix Prescrire 2010

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Paris, 7 octobre 2010 —

Mesdames, Messieurs,

Mes obligations d’enseignant à Chicago m’empêchent malheureusement d’être parmi vous pour la cérémonie et le débat du Prix Prescrire. Je vous envoie donc ce message afin de remercier Prescrire, et pour vous dire que c’est un réel plaisir et un grand honneur pour moi d’être sélectionné parmi les lauréats du Prix Prescrire 2010.

Ce prix signifie beaucoup pour moi, qui suis particulièrement attaché à Paris et à la France, en tant que Londonien et Européen. J’ai l’espoir que ce Prix Prescrire 2010 pourra accroître l’attention portée à la manière inconsidérée, incohérente, et parfois franchement grotesque, dont 112 nouveaux troubles mentaux ont été officiellement reconnus en 1980. Cette année-là est parue la 3e édition du Diagnostic and Statistical Manual of Mental Disorders (DSM III), aux États-Unis d’Amérique et dans le monde entier, augmentée de plusieurs centaines de pages par rapport à son avatar précédent, révolutionnant ainsi le paysage des décisions en santé mentale dans nos écoles, nos tribunaux, nos prisons et nos systèmes de santé.

La phobie sociale, l’un des nouveaux troubles les plus remarquables, y est décrite comme avérée si un individu évite de se rendre dans les toilettes publiques, n’aime pas s’exprimer en public, et s’inquiète de faire des taches à sa cravate au restaurant – si toutefois, bien sûr, il porte une cravate au restaurant. Malheureusement, ce n’est pas une plaisanterie. Lorsque plus de la moitié de la population – que ce soit en France ou même aux États-Unis d’Amérique – se définit comme timide, inclure dans un diagnostic psychiatrique la peur de parler en public revient quasiment, et c’est troublant, à considérer l’introversion comme un trouble mental. Au point qu’un avertissement a été inséré dans le DSM sur les risques d’une telle confusion. Au point que les laboratoires pharmaceutiques flairent un marché potentiel mondial de 2 milliards de dollars. Le résultat ? Actuellement des millions d’enfants et d’étudiants prennent, entre autres antidépresseurs et antipsychotiques, du Deroxat° ou Paxil°, nom sous lequel il est connu aux États-Unis, ou Seroxat° en Grande-Bretagne. Pour dépister les véritables effets d’un médicament sur la santé publique, voyez-vous, il faut parler couramment le langage des labos, « la pharmalangue », et exposer sans relâche au grand jour les données secrètes de l’industrie pharmaceutique.

L’Association américaine de psychiatrie (American Psychiatric Association) ne se rendait sans doute pas vraiment compte de ce que contenaient réellement ses archives, lorsqu’elle m’a accordé, ainsi qu’à mon éditeur, l’autorisation illimitée de citer tout ce que je pourrais y découvrir. Mais ce que j’y ai trouvé plus ou moins par hasard était aussi surréaliste qu’inquiétant – et jusqu’à des arguments scientifiques justifiant la reconnaissance officielle de nouveaux troubles mentaux reposant parfois sur le comportement d’un seul patient (il est malheureux, et surprenant, que nous devions toujours croire le psychiatre, même dans ce cas).

Même un gamin de cinq ans aurait rougi des querelles dont j’ai été le témoin, entre des universitaires discutant lesquelles de leurs recherches et conclusions devaient figurer dans un des manuels de diagnostic les plus influents au monde. J’ai suivi des discussions au cours desquelles d’éminents psychiatres écrivaient à leurs détracteurs ou adversaires pour diagnostiquer chez eux les troubles même qu’ils essayaient de faire valider officiellement. J’ai également retrouvé des arguments utilisés pour faire reconnaître de nouveaux troubles mentaux, qui non seulement faisaient référence au roman de Lewis Carroll, Alice au Pays des merveilles, mais qui donnaient également l’impression, tout comme Alice, d’être en chute libre dans un terrier de lapin intellectuel, ou d’assister à une tea-party chez le Chapelier fou.

Le président du groupe de travail DSM-III, Robert Spitzer, a pondu en quelques minutes les critères définissant deux troubles mentaux : même ses collègues stupéfaits n’en revenaient pas. L’un des participants a déclaré plus tard au magazine The New Yorker (janvier 2003) : « Il y avait très peu de recherche méthodique [dans ce que nous faisions], et une grande partie de la recherche menée n’était en réalité qu’un méli-mélo de données disparates, incohérentes et ambiguës. La plupart d’entre nous étaient bien conscients que nos décisions reposaient sur très peu d’informations scientifiques solides et réellement validées.»

Les aspects les plus surréalistes du roman de Lewis Carroll restent bien sûr du domaine de la fiction. Malheureusement ce n’est pas le cas de la « personnalité évitante », qui a été transformée en trouble mental suite à une discussion portant sur la question de savoir si les personnes susceptibles d’être diagnostiquées comme “évitantes” préféraient se rendre au travail en voiture ou en train (cela se passait à New York, l’une des rares grandes villes américaines à posséder un important réseau ferré). Que le géant anglo-américain GlaxoSmithKline ait dépensé en 2000 plus de 92 millions de dollars pour une campagne destinée à diagnostiquer la phobie sociale, ce n’est pas non plus de la fiction : la campagne était intitulée « Imaginez que vous êtes allergique aux autres ».

Dans de telles circonstances, on peut très bien avoir l’impression d’être tout à coup plongé dans l’univers du film Blade Runner ; ou bien de se retrouver dans une scène du roman d’Aldous Huxley, Le meilleur des mondes, dans lequel le produit appelé « soma » est si omniprésent, que l’on en prend pour se protéger de la moindre souffrance. Mais nous sommes en 2010, et c’est notre monde, et notre culture. Et de telles confusions sont déprimantes et bien réelles. Ainsi le New England Journal of Medicine a révélé, en janvier 2008, que toute l’histoire, longue de 18 ans, des antidépresseurs inhibiteurs sélectifs de la recapture de la sérotonine (IRS), avait été biaisée du fait que des données négatives avaient été déformées ou minimisées. Des essais cliniques entiers ont ainsi été relégués au fond des tiroirs, sans jamais voir le jour, parce que leurs résultats ne correspondaient pas au résultat souhaité par la firme pharmaceutique en question – qui en effet payait pour faire évaluer son propre médicament. En conséquence de ce passé tout récent, et de ces données scientifiques si peu fiables, nous avons médicalisé des millions d’individus à travers le monde.

Ces jours-ci, un débat très sérieux secoue le milieu universitaire aux États-Unis et ailleurs, pour établir si l’apathie (l’un des effets indésirables des antidépresseurs IRS, ne l’oublions pas) devrait figurer dans le DSM-5 en tant que trouble mental. Les experts continuent d’évaluer pendant combien de temps au juste nous pouvons (ou devons) travailler ou jouer en ligne, avant que le diagnostic de « Trouble de dépendance à l’Internet » nous soit appliqué. Au début de l’année, des débats prétendument “médicaux” autour du Trouble d’hyperactivité sexuelle se sont focalisé sur les problèmes matrimoniaux de plusieurs personnalités en vue : des spécialistes ont ainsi débattu très sérieusement de la question de savoir à partir de quand une activité sexuelle était suffisante ou devenait excessive, et devait être considérée comme anormale. On peut se demander ce que Foucault aurait pensé de telles conclusions, s’il avait pu en être témoin.

Ce que mon livre a permis de faire – et que l’on ne peut faire à la lecture du DSM tel qu’il est publié – c’est de reconstituer comment bon nombre de ces 112 troubles mentaux ont été créés. Comme je l’ai dit, j’ai eu accès à tous les documents, lettres et votes qui ont circulé en coulisse, et j’ai pu citer librement ces sources. Des années avant que les courriels existent, et que des informations cruciales puissent être supprimées d’une simple pression sur une touche de clavier, ces documents écrits ont été utilisés par l’Association américaine de psychiatrie pour rendre pathologiques des comportements tout à fait ordinaires tels que la peur de parler en public – des comportements pour lesquels on a prescrit, et on continue de prescrire, des antidépresseurs à des millions de personnes dans le monde entier.

Je vous remercie d’avoir reconnu l’importance de ce problème, et la nécessité de sensibiliser le public à ses conséquences quotidiennes sur nos enfants, nos étudiants, nos voisins, et nos collectivités.

Avec mes sincères remerciements,

Christopher Lane

Chicago, 23 septembre 2010                                    Traduction © Prescrire

Addicted to Addiction

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REPOSTED (orig. June 1, 2008) —

A short while ago, Mark Bittman wrote a smart, amusing column in the New York Times about the need to take an occasional break from technology (“I Need a Virtual Break. No, Really”). A self-described “techno-addict,” Bittman was haunted by the thought of not responding to voice messages within minutes of receiving them. Too much unanswered email makes him twitchy, even panicky. “What if something important was happening,” he despairs, “something that couldn’t wait 24 hours?”

Like many of us, I’m sure, I smiled sympathetically, amazed by the lure of online news (my particular weakness, especially during election season). But I’ve always attributed that to simple interest in current affairs. I’ll gladly concede the pull and pressure of email, and follow any reasonable advice on how to reduce that stress. Anyone who works in a university—or busy office, for that matter—knows how much information today is conveyed electronically, and how rapidly one often must respond to it. So when Bittman worried that he might be suffering from “the latest in American problems, Internet addiction disorder,” I assumed he was being largely tongue-in-cheek and laughed accordingly.

The March issue of the American Journal of Psychiatry seems to have missed Bittman’s irony and to have taken him quite literally. “Internet addiction appears to be a common disorder,” Jerald J. Block opines in an editorial urging the American Psychiatric Association to adopt it as a formal disorder in its next edition of the Diagnostic and Statistical Manual of Mental Disorders. His recommendation has led to a crop of almost surreal newspaper articles, with titles such as “Net Addicts Mentally Ill, Top Psychiatrist Says.” Given my time spent with online news, apparently I’m one of them. Worse, I’m in denial, insisting I don’t have a problem.

Block says that three “subtypes” of extreme Internet use concern him: “excessive gaming, sexual preoccupations, and e-mail text messaging.” I’m going to take a wild guess and say that last one applies to quite a few teenagers—and the middle one to a sizable number of former senators, governors, and mayors.

If the editorial had appeared a month later, on April 1st, I would have shrugged it off as a brilliant hoax designed to poke fun at the well-known and seemingly incurable addiction that has beset the APA since the early 1980s. That addiction comes in several subtypes, but all are variants of “Diagnostic Creation and Exaggeration Disorder,” which I’m hoping will find its way into DSM-5. That would be a disorder I finally could get behind. Peter Kramer once dubbed the problem “diagnostic bracket creep.” In lay terms, it refers to the organization’s sometimes-overwhelming urge to sneak a few hundred more pages and disorders into its diagnostic bible.

The addiction appears to have intensified in recent years. When the APA found it irresistible to christen commuter stress and road rage “Intermittent Explosive Disorder,” a few eyebrows were raised but the media largely turned a blind eye. Nowadays we’re a bit more skeptical, with “Internet addiction disorder” sparking bemusement, even disbelief, amid all the hand wringing.

One reason is that the line between compulsive behavior and sheer hard work is so difficult to determine, much less reliably diagnose. It would be hard enough to pinpoint in a society not already boasting a fierce work ethic, but it’s virtually impossible to isolate in one with a faltering economy, where conditions are so precarious that many work online far into the night and weekend just to hang on.

In his editorial Block voices understandable concern about the large number of schoolchildren in South Korea who fritter away hours each week texting, gaming, and surfing. Clearly, many lose perspective and let technology overwhelm their lives. Still, is that really a mental disorder in the strict psychiatric sense of the term? Is it not instead a sign that technology can be all-consuming and that along with its advantages it has serious drawbacks that need careful attention?

In the U.S., many parents and teachers also despair over the amount of time their children and students waste in cyberspace and on electronic gadgets—time that’s clearly not being spent devouring books. Yet Block is completely off-base when he argues that the remedy for this problem is medication. As he puts it, referencing a single conference paper, “About 80% of those needing treatment [for overuse of the Internet] may need psychotropic medications, and perhaps 20% to 24% require hospitalization.” Hospitalization? For gaming and text messaging? In a New York Times article in November 2007, by contrast, Martin Fackler described one of 140 government-sponsored Internet Addiction Counseling Centers in South Korea and never once mentioned medication. Their treatment programs “follow a rigorous regimen of physical exercise and group activities, like horseback riding, aimed at building emotional connections to the real world and weakening those with the virtual one.”

Block further undercuts his call for medication by concluding, “Internet addiction is resistant to treatment, entails significant risks, and has high relapse rates.” Since it’s now widely known that S.S.R.I. medication itself entails significant risks (a litany of mild-to-serious side effects) and that placebo accounts for 80% of the drugs’ effectiveness, one has to wonder why psychotropics play such a major role in Block’s bid to make “Internet addiction” a formal disorder. Robert Spitzer, chair of two earlier DSM task forces, offers one clue. He told me recently, “If you have a treatment, you’re more interested in getting the [new] category in” the manual (qtd. in Shyness 75). In this way, the APA occasionally puts the cart before the horse, using the apparent promise of medication to legitimate new diagnoses and make them appear to be bona fide illnesses.

Michael Miller, editor in chief of the Harvard Mental Health Letter, deplores this practice and is skeptical of the rush to call cyber-addicts mentally disordered. That the Internet facilitates easy connection to pornography and gambling sites doesn’t in itself mean the medium is the key problem, he usefully observes. For that and a myriad of other reasons, “it is difficult to call ‘Internet addiction’ a unified disorder,” and “probably not helpful to invent new terms to describe problems as old as human nature.”

Before we medicate yet more teenagers and adults, let’s pause and ask whether overuse of the Internet really belongs with schizophrenia and paranoia in a manual of mental disorders. Certainly we must recognize and respond to how technology is shaping—sometimes blighting—many lives. If South Korea’s treatment programs are anything to go by, the solution lies in stronger ties with other human beings, not more overblown connection with the pharmaceutical industry.

Christopher Lane, the Pearce Miller Research Professor at Northwestern, is the author most recently of Shyness: How Normal Behavior Became a Sickness.

Prozac Nation, Prozac Violence?

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REPOSTED (orig. March 1, 2008) —

Five days after the February 2008 shooting rampage at Northern Illinois University, the Chicago Tribune ran a headline that caught my eye: “Doctors: Prozac, Violence Rarely Linked.” Given the ambiguous grammar, it was hard to tell if the headline was warning doctors about links between the antidepressant and violence or quoting doctors as saying we needn’t be concerned about such links (“rarely linked”). A complete ruling on the matter would of course be reassuring. It might calm nationwide jitters that the cocktail of drugs—Prozac, Xanax, and Ambien—that Steven Kazmierczak had abruptly stopped taking, days before he went on his shooting spree, was connected with the violence that followed.

The Tribune headline implied that although there was a connection between Prozac and violence, it was not a significant one. When I read the article, however, I learned that Jeremy Manier, its author, wasn’t so sure. Quoting deep-seated concern by experts at renowned local hospitals, including the University of Chicago Medical Center and Northwestern’s Feinberg School of Medicine, he wrote: “About one-fifth of people who halt a course of Prozac-like drugs report symptoms associated with a condition known as discontinuation syndrome, which can include abdominal pain, dizziness, crying spells, irritability and even a sensation similar to an electrical shock in the patient’s arms or legs.”

A disturbingly large number of studies corroborate Manier’s statement. Warnings from experts about a host of problems tied to ending S.S.R.I. (selective serotonin reuptake inhibitor) treatment have spotlit other areas of concern about this class of medication—areas that will need exhaustive investigation before they can be considered resolved. These include the drugs’ effectiveness relative to placebo, and their published track record. The New England Journal of Medicine recently disclosed that the drugs’ successes have been consistently exaggerated over a period of seventeen years. As a result of such distortion, drugs like Zoloft appear in the pharmacological literature to be 70 percent more effective than the data tell us they actually are.

Given the prevalence of discontinuation syndrome and the erratic effect of mixing different classes of medication, no one should rush to judgment. Many variables are in play, including how differently people respond to S.S.R.I. medication; how severely disordered they were before taking it; and whether they are using it in combination with other drugs like Xanax and Ambien. But the sheer amount of guesswork surrounding such combinations, and how common they have become, should give us pause. The current concern about S.S.R.I. medication intensifies when one considers how many patients are cycling through other kinds of drugs at the same time, interactions that are not fully known or studied.

Not all discontinuation symptoms result in self-inflicted or externalized violence, a point I mention rather than minimize. But the reason the Food and Drug Administration added black-box warnings to S.S.R.I.s, alerting physicians to the risks of prescribing them to children and adolescents, was concern about their spotty track record and, in particular, indications of a link to violence. Numerous studies over the years pointed to a significant number of patients on the drugs who either attempted suicide or obsessed about doing so. The agency decided that it needed to take action. No one wanted a disturbing pattern to balloon into an established trend.

The drug companies want to relabel these symptoms as a resurgence of the original disorder. The problem they face in doing so is that discontinuation syndrome is entirely drug related. Prozac’s maker, Eli Lilly, has fought several protracted legal battles trying to dislodge evidence that its psychotropic is linked to violence—and Lilly is not the only drug maker that has had trouble making its case convincing.

As the Tribune’s Manier reminds us, Eric Harris and Dylan Klebold, the shooters at Columbine High School, abruptly stopped taking the same class of antidepressant medication days before they opened fire on their classmates. Jeff Weise, the Red Lake High School killer in Minnesota, was taking Prozac before he killed nine people and then himself. Pekka-Eric Auvinen, the eighteen-year-old who began shooting in Jokela High School, Finland, had a history of S.S.R.I. use. According to investigators, so did Seung-Hui Cho, who killed thirty-two people at Virginia Tech and wounded dozens more.

The list of other killings involving S.S.R.I. psychotropic medication is distressingly long. It includes Michael McDermott, the software engineer who went on a rampage in Massachusetts, killing nine; Byran Uyesugi, who shot seven of his colleagues in Hawaii; and Charles Carl Roberts IV, who assassinated five Amish school girls before shooting himself.

Such incidents may amount to nothing more than an awful set of coincidences. But many people are sufficiently alarmed by signs of a pattern to suggest that the repeated use of psychotropic medication is involved—that drugs are part of the problem here, rather than, as commonly assumed, its solution. With the pattern that is emerging, the standard defense by psychiatrists and drug companies—that patients’ quitting medication simply demonstrates how much it was needed in the first place—holds less water, especially in light of the black-box warnings, added to these drugs by the F.D.A, that indicate they can increase suicide ideation in patients, including in those who stop taking their medication abruptly.

Was the Tribune headline correct, then, when it called Prozac and violence “rarely linked”? The answer to that question depends in large measure on how one defines “rarely” and “linked.” Some would say that “rarely” is not a word to generate much concern, because the number it refers to is statistically insignificant. Yet according to the International Review of Psychiatry, more than 67.5 million Americans—almost a fifth of the country—have taken a course of S.S.R.I. medication. Twenty percent of them constitutes a sizable crowd—roughly the metropolitan populations of New York City and Los Angeles combined.

What about “linked”? Interestingly, Manier’s statement about the one in five patients who experience discontinuation syndrome on Prozac corroborates the words of Paul N. Jenner, who in 1998 distributed a confidential memo on this subject to executives at GlaxoSmithKline. Jenner was at the time the company’s Director and Vice President of Worldwide Strategic Product Development, so he was well placed to warn that Paxil too presented a “20 percent relapse rate.” Nevertheless, when highlighting what his report dubbed “Issues Management,” Jenner assured colleagues that “our highly skilled sales and marketing efforts” would spin “the discontinuation issue,” deflecting negative publicity by playing up Paxil’s “flexibility and control.”

In the report, at least, Jenner voiced not a shred of concern that one in five patients on Paxil was experiencing mild-to-serious side effects. (A later health report from GSK would list these as including risk of coma, birth defects, blood aggregation problems, and renal failure.) He was far more worried about the “fight for market share,” with competitors like “Lilly and Pfizer resorting to aggressive tactics to undermine Seroxat/Paxil’s growth.”

“Lilly,” Jenner complained, was “currently focusing on the issue of discontinuation, on trying to turn a disadvantage into an advantage by playing to the supposed strength of [Prozac’s] long half-life . . . providing an in-built tapering mechanism. This is clearly a marketing ploy,” he concluded, “already seen through by most psychiatrists, and a sign of desperation in the fight for market share.”

Coming from the makers of Paxil, such complaints might sound like the pot calling the kettle black. But Jenner was right that Lilly had tried to sugarcoat grave concern among clinicians and researchers about Prozac’s discontinuation syndrome—concern that helped prompt the FDA to take action, but that has not gone away, because discontinuation syndrome afflicts all ages.

As there are still so many “unknown unknowns” about S.S.R.I. antidepressants, what is needed now is a frank, open dialogue about the evidence we do have, including the efficacy and erratic effects of these medications when combined with other drug treatments. Longer clinical trials representing the full spectrum of patient reaction over six months—rather than, as is common, two weeks—would give us a clearer picture of how the brain and central nervous system react when patients come off this class of medication. As the Tribune article and a litany of studies make disturbingly clear, the evidence is mounting that these psychotropics have far more worrisome, unpredictable effects than large numbers of prescribers and drug makers would have us believe.

Christopher Lane, Professor of English at Northwestern University, is the author most recently of “Shyness: How Normal Behavior Became a Sickness.”