The Comment Factory | October 2, 2008
[original link: http://www.thecommentfactory.com/popping-pills-for-shyness/]
A few weeks ago, I received some rather disturbing news: I may be experiencing the symptoms of something called “social anxiety disorder”. After taking an online test for this, apparently the third most common “psychiatric condition” in the U.S after depression and alcoholism, I was told that I should consult my health-care provide about getting a prescription for Paxil, which may help me overcome this terrible affliction.
The thing is, I never really thought of myself as anything other than mildly introverted. Sure, I am “somewhat” bothered by blushing in front people, as question two asks – but who likes blushing in front of people? I also said that I am “very much” afraid of being criticized – who, after all, enjoys being criticized? And, like a lot of people, I “very much” try to avoid giving speeches in public. How many of us go out of their way to do public speaking?
These questions can be found on GlaxoSmithKline’s website, which it uses to convince people that shyness, a condition that makes people afraid of public speaking, of meeting strangers, and of being the center of attention, is a disorder. More worrying still, these are the kinds of symptoms that the American Psychiatric Association includes for social anxiety disorder, a condition it first mentioned in 1980 in the third edition of its so-called bible of psychiatry, Diagnostic and Statistical Manual of Mental Disorders, or DSM-III.
The medicalization of shyness is the central focus of a book by Christopher Lane with the new paperback due out in December 2008. The book’s title is also its hypothesis: Shyness: How Normal Behavior Became a Sickness. It hits two main targets: the American Psychiatric Association (APA), which Lane says arrived at classifications of what to include in its DSM-III in a haphazard way, more influenced by in-fighting and personalities than by science, and also ‘Big Pharma’, which, through clever marketing ploys, has managed to convince millions of otherwise “shy” Americans that they have an illness that needs to be treated.
The result is a thoroughly riveting polemic. Lane’s prose glides effortlessly along, and successfully deconstructs complex scientific processes for a lay audience, making it accessible, without being trivial in its treatment of a very serious topic. At the same time, the care Lane took with his research is abundantly clear.
Lane is a British professor of literature at Northwestern University in the U.S, where he specializes in Victorian fiction, with a particular interest in the interface between literature and psychoanalysis. He has also edited “The Psychoanalysis of Race” (1998) and a co-edited “Homosexuality and Psychoanalysis” (2001).
Despite his academic training, Lane said he felt “very much like an investigative journalist” when writing this book, a point that clearly comes across when he writes about the process in which DSM-III was formulated. Initially, the APA wasn’t going to give him access to its papers. Eventually, after some persuasion, it relented. He said that in the process there was much “sleuthing” involved.
“I would characterize the book as a cross between that style of journalism and what I hope is a very accessible intellectual and cultural history,” Lane said in an interview, his British accent betraying no Americanisms despite having lived here since 1992. “It looks at how psychiatry has evolved, and how it’s having a massive influence on culture in terms of the way we think about depression and anxiety.”
The fact that he is an Englishman in the U.S., he says, gave him a different perspective on this topic.
It is easier being shy in the U.K than in the U.S., whose people are considered the “most gregarious” on earth. “Being from Britain led me to perhaps question the degree to which drug companies shape our understanding of illness here in a way that they really don’t in England,” he says, adding that there is a much greater tendency to question drug companies in the U.K than in the U.S. After moving over here from London, he was shocked at the intensity and ubiquity of pharmaceutical advertising. “There’s something about being an expatriate that you don’t quite adjust completely to what’s considered ordinary or normal in your host country.”
In 1980, the DSM-III introduced 112 new disorders. It has been getting steadily thicker with each new edition since, as it uncovers more and more disorders. That year, DSM-III described social anxiety disorder, one of the new disorders, 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.”
Lane argues that because of the low diagnostic threshold set for social anxiety disorder, DSM-III failed to make the distinction between the disorder and ordinary shyness. Not until DSM-IV came out in 1994, says Lane, was there a clause inserted that stipulated that ordinary shyness should not be confused with social anxiety disorder. “But by that stage, a huge amount of damage was done, when it was basically too late,” says Lane.
Some doctors, Lane points out, believe that fears of sounding foolish and fears of being stumped when asked a question in social settings – “fears that that doubtless afflict almost everyone on the planet” – are symptoms for social anxiety disorder. “Considering these elastic guidelines,” he continues, “we can grasp quite easily why this ‘illness’ is so widely diagnosed, but it’s harder to say why so many take the diagnosis seriously, much less accept its judgment of mental debility.”
A consequence of lowering the diagnostic threshold for social anxiety disorder was that the numbers of people diagnosed with it skyrocketed. Stanford colleagues Lynne Henderson and Philip Zimbardo, for example, who are also co-directors of the Shyness Institute in Palo Alto, warned in 2006 of a “public health danger that appears to be heading toward epidemic proportions.” (When asked for this article if she thought the phrase “epidemic proportions” was overly dramatic, Henderson agreed, saying that that phrase was the choice of her co-author, and not hers.)
In 1993, Psychology Today called it the “disorder of the decade”, and estimated that the total U.S population suffering from it went from 3.7 percent to 18.7 percent. This last figure is contained in an influential 1996 article in The Lancet by Murray Stein – a psychiatrist whom Lane says has “staked his career on the need for drugs to treat reticence and social phobia.”
Especially in the early 1990s, the 18.7 percent figure and The Lancet paper were widely quoted in the pharmaceutical literature on social anxiety disorder. However, as Lane points out, Stein, who is a professor of psychiatry at the University of California, San Diego, based the 18.7 percent figure on another study which came from a random telephone survey of 526 Canadians. And in his conclusion, Stein says that the precise delineation of social anxiety disorder is dependent on where the diagnostic threshold is set – meaning that it could in fact range from 1.9 percent of the population to 18.7 percent. The first figure, however, wasn’t reported in the pharmaceutical literature, which said instead, that “one in five Americans” suffer from social anxiety disorder.
In one of the most memorable phrases in the book, Lane writes, “Before you sell a drug, you have to sell a disease.” He is perhaps at his strongest – and most acerbic – in his treatment of drug companies and the way in which their promoted of social anxiety disorder lead to it being thought of as a major phenomenon.
In 1998, the FDA approved Paxill for treatment of social anxiety disorder. (It had been previously been mainly prescribed as an anti-depressant.) Then, SmithKline (since called GlaxoSmithKline following a merger in 2000) set about the task of selling the disease. Through the public relations firm Cohn and Wolfe, it sought to promote “awareness” of social anxiety disorder. The trade journal PR News reported that SmithKline resolved to “position social anxiety disorder” as a “severe medical condition.” The company’s product director, Barry Brand, was perhaps being ill-advisedly candid when he explained to Advertising Age, “Every marketers dream is to find an unidentified or unknown market and develop it. That’s what we were able to do with social anxiety disorder.”
In 1999, SmithKleine wallpapered bus shelters across the U.S with posters featuring a dejected looking young man, and the tagline, “Imagine Being Allergic to People,” explaining, “That’s what social anxiety disorder feels like.” There was no mention on these posters of Paxil or of SmithKline. A group called the social anxiety disorder coalition and its three non-profit members, the American Psychiatric Association, the Anxiety Disorders Association of America, and Freedom from Fear, were, however, listed. As Lane explains, this gave the impression of the coalition being some sort of grassroots campaign. But according to a 2002 report in Mother Jones, Cohn and Wolfe handled all media enquires for this group, which Mother Jones said had been “cobbled together” by SmithKleine. Freedom from Fear, according to Lane, was quietly being bankrolled by SmithKleine behind the scenes.
GlaxoSmithKline declined to be interviewed for this article. However, Dr. Darell Regier, the director of research at the American Psychiatric Association (who also currently serves as vice-chair of the task force to develop DSM-IV, expected finished in 2012), said that while there was a clear marketing benefit for drug companies, “direct consumer advertising can be really helpful in de-stigmatizing depression and bringing it to public awareness.”
Regier says that it wasn’t so much that drug companies were creating illness in people, as uncovering them – which explains the spike in the numbers of people who supposedly suffer from social anxiety disorder. “One of the things that happens in medicine,” he says, “is that illnesses tend to emerge more clearly when there are adequate treatment for them. When they discovered that lithium was an effective treatment for manic depression, you had a significant increase in recognition of manic depression. The same was true for obsessive compulsive disorder – it was once thought to be rare.”
Predictably, some in the psychiatric community have reacted angrily to Lane’s book, which has received a great deal of media attention. Its introduction appeared in the Wall Street Journal, and because of the publicity surrounding it, Lane has written op-ed pieces for The New York Times and The Washington Post, as well as having appeared on BBC radio. When asked about it, one employee of an association for social anxiety disorders, told me, “You know he’s just a journalist, right?” Psychiatrists have been on the defensive.
Dr Murray Stein, a much maligned figure in the book, said that claims that millions of shy people were coming out in droves to take medication for “mere shyness” were simply not supported by any research. “I can count on one hand in 20 years how many people have come to me asking for treatment for social phobia where I thought it was unwarranted, “ he said, adding that he thought the book was very well-researched and well-worth reading. “Think about it. Who goes out of their way to take costly medications with substantial side effects for ‘normal shyness’? It just doesn’t happen.”
A central character in his book is Robert Spitzer, a professor of psychiatry at Columbia University, the chair of a taskforce that oversaw DSM-III. Spitzer – described in a New Yorker profile as “one of the most influential psychiatrists of the twentieth century” – told the newspaper Chicago Reader that Lane implies that what “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.”
This argument – that psychiatrists make the distinction between ordinary shyness and social anxiety disorder – is something that Lane balks at. “I acknowledge that distinction – probably not as prominently as I could have, but it’s there,” he says. “What I also try to get at is that the distinction between mild shyness and chronic impairment has been basically lost by psychiatry. When you look at the psychiatric literature, psychiatrists themselves repeatedly acknowledge that the difficult between shyness and social anxiety disorder is in fact far more difficult to establish.”
One of the books he criticizes for being vague on this distinction between shyness is a book called Social Anxiety Disorder: A Guide. “Some social anxiety disorder,” the book says, “is expected in everyone.” In an interview, one of its co-authors, John H. Greist, responded angrily to this charge, calling the distinction “semantic.” “Look,” Greist, a psychiatrist at the University of Wisconsin, continued, “When a patient comes in and tells me, ‘I’m shy and I can’t go to a public bathroom because of my shyness, or I can’t eat because of my shyness, I don’t have to have a label. If they are coming to me and saying this causes me distress or dysfunction, I don’t care what the hell you label it.”
Some of Lane’s critics also argue he degrades social anxiety disorder, which could ultimately be very damaging for suffers of this condition. “When someone writes about it as if it isn’t a very real or serious condition,” says Dr. Jerilynn Ross, the head of the Anxiety Disorders Association of America, “that’s very sad for people who have the disorder.”
Arlin Cuncic, who writes about social anxiety disorder for About.com, says, “I think it is unfortunate that Dr. Lane has made an example of SAD because people who are diagnosed with this disorder truly do suffer – a fact that Dr. Lane seems to overlook. His position definitely trivializes SAD. This may cause the medical community to be more complacent about SAD symptoms in their patients, and miss making the diagnosis when it is in fact appropriate.”
One of the book’s main focus of criticism – the American Psychiatric Association – has also been especially critical of Lane. Dr. Darrel Regier said that Lane misrepresented what he was doing when he asked the association for its archived material. “He came in as an academic looking at the various archives we have on the DSM,” says Regier. “The expectation was that this was more of a serious history of science type report. In fact, it was more of a creative writing exercise.”
(Interestingly, the association’s journal, the American Psychiatric Journal, chose not to review the book. According to Regier – who stressed that he doesn’t sit on the journal’s editorial board – this was because it “isn’t a serious scientific book.” Regier expressed surprise when he was told that the book was well received in the highly-regarded medical publication, The New England Journal of Medicine, whose reviewer, Dr. Brian Cox, said he “would highly recommend it for psychiatry residents.” Elsewhere in the British medical journal The Lancet, the reviewer described Lane’s book as “splendid.”)
Regier says that because of Lane’s background in fiction criticism, he was venturing too far outside of his own field – a common complaint among Lane’s detractors. “He has an interest in this area,” says Regier, “He decided it was hot from a publishing standpoint and decided to pursue it.”
Dr. Murray Stein, a frequent media commentator on social anxiety disorder, voiced similar complaints. In an email he said that Shyness was “written by an English professor who has never treated people with social phobia. If he had, he would know that these are individuals whose “shyness” is anything but normal, and anything but trivial. For them, their social anxiety is a curse. When they hear that treatments are available, many – certainly not all – seek treatment.”
Lane said he was conscious of the fact that the psychiatric community would hit back by saying that he should stick to the fiction. As such, he says that the book was fact-checked numerous times, and that he took various classes at Northwestern School of Medicine, where colleagues reviewed the medical material in the book. “Nothing would have been worse,” he says, “than for an English professor to have gone beyond their level of expertise and produce something that is factually inaccurate.” However, the fact that he is not a psychiatrist, he says, was in many ways, a blessing. “I was able to say to people in interviews,” he says, “‘Can you rephrase that in way that makes sense to someone without specialist understanding?’”
Finally, I ask him Lane if he considers himself shy. “I was shy as a teenager,” he says. “And I worked through it. Now I am professor who regularly lectures to upwards of a 100 students, twice a week. I’ve done live radio with maybe over a million people – it’s living proof that it’s possible to work though shyness and not let it be completely incapacitating.”