Monday, September 24, 2007

Shyness: Pathological or Normal Experience

SmikeKlineBeecham/GlaxoSmithKline, the psychiatric elites who devised the Diagnostic and Statistical Manual of Mental Disorders, and social phobia. An interesting combination. I read a fascinating op-ed in the New York Times by Christopher Lane , an English professor at Northwestern University that discussed the growth of social phobia, especially among kids. Here are some highlights...

"How much credence should we give the diagnosis? Shyness is so common among American children that 42 percent exhibit it. And, according to one major study, the trait increases with age. By the time they reach college, up to 51 percent of men and 43 percent of women describe themselves as shy or introverted. Among graduate students, half of men and 48 percent of women do. Psychiatrists say that at least one in eight of these people needs medical attention.

"But do they? Many parents recognize that shyness varies greatly by situation, and research suggests it can be a benign condition. Just two weeks ago, a study sponsored by Britain’s Economic and Social Research Council reported that levels of the stress hormone cortisol are consistently lower in shy children than in their more extroverted peers. The discovery upends the common wisdom among psychiatrists that shyness causes youngsters extreme stress. Julie Turner-Cobb, the researcher at the University of Bath who led this study, told me the amounts of cortisol suggest that shyness in children “might not be such a bad thing.” [Not sure that this finding in itself is strongly suggestive of anything important, but it's interesting.]

Lane goes on to write about his perception that the diagnostic criteria are too loose for social phobia. Then, enter Paxil.

Then, having alerted the masses to their worrisome avoidance of public restrooms, the psychiatrists needed a remedy. Right on cue, GlaxoSmithKline, the maker of Paxil, declared in the late 1990s that its antidepressant could also treat social anxiety and, presumably, self-consciousness in restaurants. Nudged along by a public-awareness campaign (“Imagine Being Allergic to People”) that cost the drug maker more than $92 million in one year alone ($3 million more than Pfizer spent that year promoting Viagra), social anxiety quickly became the third most diagnosed mental illness in the nation, behind only depression and alcoholism. Studies put the total number of children affected at 15 percent — higher than the one in eight who psychiatrists had suggested were shy enough to need medical help.

This diagnosis was frequently irresponsible, and it also had human costs. After being prescribed Paxil or Zoloft for their shyness and public-speaking anxiety, a disturbingly large number of children, studies found, began to contemplate suicide and to suffer a host of other chronic side effects. This class of antidepressants, known as S.S.R.I.’s, had never been tested on children. Belatedly, the Food and Drug Administration agreed to require a “black box” warning on the drug label, cautioning doctors and parents that the drugs may be linked to suicide risk in young people.

You might think the specter of children on suicide watch from taking remedies for shyness would end any impulse to overprescribe them. Yet the tendency to use potent drugs to treat run-of-the-mill behaviors persists, and several psychiatrists have already started to challenge the F.D.A. warning on the dubious argument that fewer prescriptions are the reason we’re seeing a spike in suicides among teenagers. [Note that I tackled this recently.]

It goes on to close with...

With so much else to worry about, psychiatry would be wise to give up its fixation on a childhood trait as ordinary as shyness.

To view the diagnostic criteria for social phobia, please go here. Here is a key symptom:

"The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia."

The diagnosis depends to a large extent what the doctor considers as "interferes significantly" or as "marked distress." When Paxil was being pushed, I'd be willing to bet that the reps were given scripts that helped to expand the boundaries of social anxiety disorder. When words like "significantly" or "marked" are used, one has to wonder what they mean? Who shapes physicians' judgment on these matters? To a notable extent, physician perceptions are influenced by commercials, er, continuing medical education and cheerleaders, er, drug reps.

A great piece from the New Republic in 1999 relevant to the expansion of social phobia can be found here. The points raised in the article ring true today. Let me be clear: I've seen real social phobia -- it exists and it is painful. But does it really affect 13% of Americans? I think not. I'm quite glad that Dr. Lane is stepping into the fray. I'm not sure I agree with him wholeheartedly, (I'll have to read his upcoming book first), but I know that I'm glad someone is willing to bring these issues to the fore. At the very least, this is a subject worthy of debate and discussion, not blind acceptance of the current orthodoxy that social phobia (like everything else) is underdiagnosed and undertreated.


KLF said...

I would first like to say that I enjoyed your link to and commentary on Christopher Lane’s piece in the Times. I agree with your assertion that too many people are being diagnosed with social phobia if your figure of 13% is correct. In my opinion, a clinically significant psychiatric condition should, by definition, be something that occurs in a very small percentage of the population. Otherwise every single unfavorable aspect of human nature may one day be labeled as a disorder worthy of “treatment.” However, I partially disagree with your blaming the majority of the over diagnosis problem on drug companies. Also significant, in my view, is the fact that too many patients (and parents of patients) want something tangible to come of every doctor’s visit. The fact that these people are consulting with psychiatrists in the first place suggests that they are proactively looking for something to “cure” them. I imagine many would not be satisfied if their psychiatrist simply said there was nothing wrong with them. For many people, leaving the office with a diagnosis and a prescription makes the visit seem worthwhile. The same phenomenon can be seen in the over prescribing of antibiotics for viral illnesses that doctors know antibiotics won’t cure. Unfortunately, the side effects of psychoactive drugs are much more serious than those of common antibiotics.

CL Psych said...


Sorry for the long delay in responding. I'm guessing that you're probably correct that many patients go to a doctor fully expecting to receive some form of diagnosis and a pill.

I think much of the reason why people expect to receive a diagnosis is due to the flood of advertising, news reports, and the like that discuss how common various ailments are and the tragedy of undertreatment. In some cases, these warnings are valid, but others are puff pieces that merely serve to market a disorder beyond what is sensible.

Of course, our society that thrives on impatience and a demand that all must be cured immediately is partly to blame. I suspect that many people who are having existential issues believe they are suffering from a mental disorder and that it needs treatment.

And the drug industry has done a marvelous job of putting out the idea that mental disorders are causes by a known chemical imbalance that is brought into balance by medication, which is patently ludicrous based on our current scientific understanding.