What's wrong with being shy?

Oct 12 2007

What's wrong with being shy, and just when and how did bashfulness and other ordinary human behaviors in children and adults become psychiatric disorders treatable with powerful, potentially dangerous drugs?, asks a Northwestern University scholar in a new book that already is creating waves in the mental health community.

In “Shyness: How Normal Behavior Became a Sickness” (Yale University Press, October 2007), Northwestern's Christopher Lane chronicles the “highly unscientific and often arbitrary way” in which widespread revisions were made to “The Diagnostic and Statistical Manual of Mental Disorders” (DSM), a publication known as the bible of psychiatry that is consulted daily by insurance companies, courts, prisons and schools as well as by physicians and mental health workers.

“The number of mental disorders the general population might exhibit leaped from 180 in 1968 to more than 350 in 1994,” notes Lane, Northwestern's Herman and Beulah Pearce Miller Research Professor. In a book that calls into doubt the facade of objective research behind psychiatry's revolution, Lane questions the rationale for the changes, and whether all of them were necessary and suitably precise.

By labeling shyness and other human traits as disorders with biological causes, the doors were opened wide to a pharmaceutical industry ready to provide a pill for every alleged chemical imbalance or biological problem, the author says.

Lane, who meticulously and systematically researched the archives of the American Psychiatric Association, uses social anxiety disorder (first dubbed social phobia) as the lens through which to analyze American psychiatry's extraordinary shift in the last 30 years from a psychoanalytic orientation relying on talk therapy to its current emphasis on neuroscience and drugs.

He draws on previously neglected letters and memos written by the framers of the new disorders to argue that DSM revisions to social phobia or social anxiety disorder placed the diagnostic bar too low, turning social anxiety into a mental illness common enough to be considered, according to recent studies, third only to alcoholism and major depression.

The DSM continues to stipulate that social anxiety disorder (SAD) must be “impairing” for a diagnosis to occur. The problem, Lane argues, is that DSM-defined symptoms of impairment in 1980 included fear of eating alone in restaurants, concern about hand trembling while writing checks, fear of public speaking and avoidance of public restrooms.

By 1987 the DSM had removed the key phrase “a compelling desire to avoid,” requiring instead only “marked distress,” and signs of that could include concern about saying the wrong thing. “Impairment became something largely in the eye of the beholder, and anticipated embarrassment was enough to meet the diagnostic threshold,” says Lane.

“That's a ridiculous way to assess a serious mental disorder, with implications for the way we also view childhood traits and development, given the increased focus on reticence,” Lane adds. “But that didn't stop SAD from becoming what Psychology Today dubbed ‘the disorder of the 1990s.'”

In addition to providing extensive documentation from the American Psychiatric Association archives, Lane includes previously confidential material from the drug companies themselves that present a worrisome history of the antidepressant Paxil.

The drug came onto the marketplace in 1996 despite the fact that its makers earlier had considered shelving it because of poor performance and early signs of side effects in clinical trials. Using a memo circulated among drug company executives, Lane presents evidence that a lot of information about the drug's poor track record was withheld from the public.

When Paxil became the first drug approved by the Food and Drug Administration for the treatment of social anxiety disorder in 1999, however, its makers launched a $92 million awareness campaign on the theme “Imagine Being Allergic to People.” This and other advertising campaigns helped change the way Americans think about anxiety and its treatment.

“Every marketer's dream is to find an unidentified or unknown market and develop it. That's what we were able to do with social anxiety disorder,” a product director for the drug told Advertising Age magazine. In 2001, with 25 million new prescriptions written for Paxil, the drug's U.S. sales alone increased by 18 percent from the year before.

Although psychiatrists insist that the line between ordinary shyness and social anxiety disorder (SAD) is sharply defined, Lane points to psychiatric literature that repeatedly confuses them, putting patients at risk of over-diagnosis and unnecessary, sometimes harmful treatment.

A professor of English in Northwestern's Weinberg College of Arts and Sciences, Lane previously directed a psychoanalytic studies program in Emory University's psychiatry department. Long interested in psychology, he presents evidence of a burgeoning backlash to psychiatry's current trends in the form of analyses of novels including “The Corrections” by Jonathan Franzen and “The Diagnosis” by Alan Lightman, as well as the film “Garden State” by Zach Braff.

Lane, who was awarded a Guggenheim Fellowship to study psychopharmacology and ethics, audited medical courses and invited psychiatrists and pharmacologists to review his book, particularly a chapter on rebound syndrome. That term refers to a boomerang effect experienced by some patients on discontinuing Paxil that is more intense and dangerous than the turmoil that caused them to take the drug in the first place.

In examining the American Psychiatric Association archives, Lane -- who argues that psychiatry is using drugs with poor track records to treat growing numbers of normal human emotions -- even came across a proposal to establish “chronic complaint disorder,” in which people moan about the weather, taxes or the previous night's racetrack results.

“It might be funny,” he says, save for the fact that the DSM's next edition, due to be completed in 2012, is likely to establish new categories for apathy, compulsive buying, Internet addiction, binge-eating and compulsive sexual behavior. Don't look for road rage, however. It's already in the DSM, under intermittent explosive disorder.