Shy of a Phobia

Jacob Sullum | September 24, 2007

Christopher Lane, author of the new book Shyness: How Normal Behavior Became a Sickness, argues in a New York Times op-ed piece that psychiatrists should stop pathologizing and medicating shy children. Instead, he says, they should restrict themselves to pathologizing and medicating really shy children:

It may seem baffling, even bizarre, that ordinary shyness could assume the dimension of a mental disease. But if a youngster is reserved, the odds are high that a psychiatrist will diagnose social anxiety disorder and recommend treatment.

Lane, a professor of English at Northwestern University, attributes the problem to "the diagnostic criteria for shyness" in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, which he says "are far from clear." According to the 1980 edition, Lane writes, someone could be diagnosed with "social phobia" if "he was afraid of eating alone in restaurants, avoided public restrooms or was concerned about hand-trembling when writing checks." The 1987 edition "expanded the list of symptoms by adding anticipated concern about saying the wrong thing, a trait known to just about everyone on the planet." The solution, Lane says, is to "reconsider the diagnostic standards" so as to "carefully distinguish normal—even healthy—shyness from social anxiety disorder." 

Far be it from me to defend the APA, but the definition of social phobia (a.k.a. social anxiety disorder) in the 2000 edition of the DSM requires "marked and persistent fear of one or more social situations" that the individual himself recognizes as "excessive or unreasonable" and that "interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships" or causes "marked distress about having the phobia." It's pretty clear that the condition is supposed to go beyond "ordinary shyness," although there's a lot of room for interpretation, especially when a psychiatrist is dealing with a child who may not be adept at reflecting on his own feelings and behavior.

But tinkering with the diagnostic criteria misses the point. The problem is not that psychiatrists are overdiagnosing social anxiety disorder; it's that social anxiety disorder is whatever psychiatrists say it is. As with almost all the other "disorders" listed in the DSM, there is no underlying biological condition that can be measured objectively, despite all the talk about using SSRIs such as Prozac and Zoloft (the preferred treatment for social phobia) to correct hypothesized chemical imbalances in the brain. Indeed, the fact that so-called anti-depressants are used to treat a wide variety of conditions, and actually seem to be more effective at relieving anxiety than they are at relieving depression, suggests the DSM's behavior-based taxonomy does not reflect clear etiological distinctions.

People with crippling fear of social situations should be free to seek help from psychiatrists, including drugs that help them function better. Parents should be free to seek such help for their children. But hasty use of SSRIs might be avoided if we stopped seeing such social anxiety as a disease akin to cancer or tuberculosis, where a physical process can be identified and treatment recommended on that basis. A social phobia diagnosis is nothing more than one person's opinion that a given individual's shyness is extreme. Differences of opinion about such matters, unlike differences of opinion about whether someone has cancer or tuberculosis, cannot be conclusively resolved, even by a new, improved DSM.

Comments

|9.24.07 @ 1:22PM|#

Well, if you're not an extrovert you're NOT AN AMERICAN! PUNK QUIET EURO-WEENIE!

SIV|9.24.07 @ 1:28PM|#

"the diagnostic criteria for shyness" in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders
Peer reviewed Consensus of Professionals...etc

Science has spoken.
Silence! You deniers.
Vee hav diagnosis for you too.

|9.24.07 @ 1:29PM|#

Without SSRIs I was unable to leave the house, so I can honestly say Lexapro completely changed my life. I don't know if it's a disease or what, I just know I like the fact that people research treatments for such questionably biological disorders.

VM|9.24.07 @ 1:33PM|#

this is the fun flipside to the overly esteemed kids who, as adults, don't seem to have appropriate monitoring skills ("indoor behavior").

For instance, people who get worked up over parlor games ("competition" without preparation)

:)

*mimes in a box.

|9.24.07 @ 1:41PM|#

Psychiatry, and it's illegitimate offspring psychology, has long tried to describe some personalties as disoreder, requiring expensive and doubtfully effective treatments. Are they completely full of it? Nah. Are they completely full of themselves, I'd say so. If you want a good laugh at the profession, read Running With Scissors.

Russ 2000|9.24.07 @ 1:46PM|#

Because I'm afraid of the police and the criminal justice system, I'm too shy to ask my pharmacist for some Zoloft without a prescription. Thanks to my shrink I can get past the gatekeepers, but I'd be a lot better off if the SSRI's were OTC.

|9.24.07 @ 1:51PM|#

I'm with John-David. I was non-functional without Zoloft. There are only so many times you can sit in your dark apartment because you were too anxious to pay your power bill -- to even *open* the power bill and see how much it was -- before you have to admit you have an actual problem.

|9.24.07 @ 2:00PM|#

My daughter was labeled with "oppositional defiance disorder" a few years back. I laughed when I heard that, thinking that if given the chance, the psychiatric industry will eventually label every non-trivial behavior with some type of syndrome or chronic state. She's a stubborn (and defiant) kid!

But after years with her screaming NO!, no matter what the request and no matter how we try to mitigate this behavior, I may have to revise my earlier opinion and that they may be onto something. This kid just ain't rational when it comes to parental requests/demands. Can't wait for her teenage years.

The punch line is that there is no pill for this disorder per se, but we are making s-l-o-w progress. Luckily, there are alternate treatments for her parents, usually in the form of self-medication through home-made margaritas or a decent bottle of red.

JMR|9.24.07 @ 2:03PM|#

The behavior of children is being pathologized by the "mental health" profession long before they're old enough to be shy - they have recently cooked up two new subsets of depression "disorders" and five new sets of anxiety "disorders" for infants. Infants! Things like "separation anxiety" are now official infant mental health problems.

|9.24.07 @ 2:13PM|#

"Without SSRIs I was unable to leave the house, so I can honestly say Lexapro completely changed my life. I don't know if it's a disease or what, I just know I like the fact that people research treatments for such questionably biological disorders."

John David, Lexapro has really helped me with my OCD.

SIV|9.24.07 @ 2:20PM|#

As with almost all the other "disorders" listed in the DSM, there is no underlying biological condition that can be measured objectively

Objective measurement may have been fine in Isaac Newton's day but the new gold standard is peer review. Repeatable experiments are so Dark Ages.Appeal to authority, it is good for you.

|9.24.07 @ 2:25PM|#

I'm not sure of that. I've read of plenty of studies on every psychiatric drug. Check www.crazymeds.org for more information than you can shake a stick at.

robc|9.24.07 @ 2:31PM|#

JW,

Have you considered the University of Minnesota Spankological Protocol?

|9.24.07 @ 2:40PM|#

robc,

LOL. That'll fix the kidderino right up. She'll be okely-dokely in no time.

|9.24.07 @ 2:45PM|#

Jacob--

You kind of miss the point in Lane's NYT piece (even though you end up making a surprisingly similar one to him!). The DSM criteria do indeed stipulate that the social anxiety must be "excessive," but the criteria they list are far from being so. Lane is quite right that they list hand-trembling when writing checks, embarrassment about eating alone in restaurants, and avoidance of public restrooms. How on earth could those be considered "excessive"? The fact remains that psychiatrists and doctors use such lists to overprescribe what remain very dangerous drugs that have never been tested on children. But you've written a book in defense of medication (including on 3 yr olds, which is what some zealots are recommending?), so I don't think we can really trust your perspective to be balanced, can we?

Paul|9.24.07 @ 2:53PM|#

avoided public restrooms or was concerned about hand-trembling when writing checks."

I must be very, very sick.

Jennifer|9.24.07 @ 2:53PM|#

Thank God oppositional defiant disorder hadn't been invented yet when I was a teenager. No snark there; I'm entirely serious.

Paul|9.24.07 @ 2:56PM|#

I always believed that the desire to control other people's lives was a mental illness. Just sayin'

|9.24.07 @ 3:01PM|#

Reason -- the site preferred by people with Oppositional Defiant Disorder! Act now!

Maybe if every monthly delivery of Reason magazine came with a supply of Zoloft ...

Seriously, are we to believe that the people content with being micromanaged and ripped off by the gang of thugs running government are the normal, well-adjusted ones?

|9.24.07 @ 3:04PM|#

robc--You kidding? I'm a founding memeber of the Institute. Trust me. It's not for a lack of discpline in Casa de JW.

Doesn't help though. If it were only that easy....and to think before I became a parental unit my policy was to not negotiate with terrorists. :::sigh:::

|9.24.07 @ 3:08PM|#

Maybe if every monthly delivery of Reason magazine came with a supply of Zoloft ...

Now, if it starts coming with a nice bottle of 100% blue agave anejo, I may have to start renewing my sub early.

|9.24.07 @ 3:18PM|#

Cognitive Behavioral Group Therapy was shown to be as good as (and sometimes better) than psychotropic medications for Social Phobia.

Google Heimberg and Liebowitz.

|9.24.07 @ 3:20PM|#

OK... I'll *think* about medicating my kids when they have some objective test that shows me they are lacking something that a drug can provide: an EKG, a chemical test, anything. As long as diagnosis is done by non-objective analysis I refuse to even consider the possibility. I have no idea why anyone else would NOT follow this advice. You have difficult children? Tough! that's the way the cookie crumbles.

|9.24.07 @ 3:31PM|#

RA,

How do you get social phobics to go to group therapy? ;-}

Roberto Leibman,

What about autism?

Episiarch|9.24.07 @ 3:35PM|#

Have you ever tried simply turning off the tv, sitting down with your children, and hitting them?

JMR|9.24.07 @ 3:36PM|#

Cognitive Behavioral Group Therapy was shown to be as good as (and sometimes better) than psychotropic medications for Social Phobia.

If Cognitive Behavioral Group Therapy makes someone "better" - then there was nothing medically wrong with them to begin with.

|9.24.07 @ 3:40PM|#

As long as diagnosis is done by non-objective analysis I refuse to even consider the possibility. I have no idea why anyone else would NOT follow this advice.

Oh gee, I don't know, so maybe she doesn't become a total freak-show, parasitic loser when she grows up, assuming she doesn't off herself before she's 15?

The behaviors my daughter has aren't cut and dry like add, autism or asperger's (even those aren't all that cut and dry), but her behaviors are complex and diverse enough to defy a clear diagnosis as yet. That said, there is clearly something not right with her.

I would trade mucho for someone who could diagnose and treat her effectively (bringing a semblance sanity to my household) and help my daughter grow up to be a normal, functioning adult.

Difficult children? Tough shit? Walk a mile, bud, walk a mile.

Thomas Paine\'s Goiter|9.24.07 @ 3:44PM|#

Everyone has to have their problem I guess. If you don't have some disorder or disease, how will you one-up people at cocktail parties?

Dr Spock|9.24.07 @ 4:05PM|#

Might I suggest eliminating HFCS from your child's diet.Might not help with the behavior but guys dig skinny crazy chicks with good teeth more than fat diabetic crazy chicks with cavities.

|9.24.07 @ 5:08PM|#

What about autism?

What about it? I'm not saying that autism doesn't exist (or any other "mental" disease for that matter), or even that diagnosis cannot be supported by behavioral observations... just that medication should follow scientific guidelines: you're brain is missing this... so we give it that. My brain is to precious to be modified willy-nilly, that of my growing children even more so.
You say there's a mental disease (an impairment of health or a condition of abnormal functioning) called autism... I don't dispute it. It must have a set of causes, each cause may have a physical and a psychological component. To fix the psychological components you can't prescribe drugs, that's where psychology comes in. For the physical aspects I am very leery of adding a chemical mixture to such a delicate machine as the brain... again: tell me what's missing before you start messing with brain chemistry.
C'mon... it's called reason, let's use it!

|9.24.07 @ 5:15PM|#

C'mon... it's called reason, let's use it!

What you want doesn't exist. It would be nice if did, but wishful thinking isn't science. It's not reason either. Reason is working wihth the best tools availble. Not sitting there and doing nothing because they aren't available.

There is no test for chronic pain, other than what the patient reports. True, there are physical markers that tells you if someone is in pain, but not to what degree that they are.

Should we tell them "tough shit" since there is no test for their condition?

Now, everyone drink!!

|9.24.07 @ 5:23PM|#

The behaviors my daughter has aren't cut and dry like add, autism or asperger's (even those aren't all that cut and dry), but her behaviors are complex and diverse enough to defy a clear diagnosis as yet. That said, there is clearly something not right with her.

I would trade mucho for someone who could diagnose and treat her effectively (bringing a semblance sanity to my household) and help my daughter grow up to be a normal, functioning adult.

Precisely my point! You don't know what's going on with your daughter's brain, why would you subject her to drugs that may only complicate matters? What if she really is special and has special potentials that any of the currently overprescribed medicines is going to kill. If current medical knowledge is not enough to treat her, don't treat her just to do something, that's quackery.

Difficult children? Tough shit? Walk a mile, bud, walk a mile.

There are, close to me, difficult children (not mine, frankly... they are perfect :) ). And at least one of these has been greatly helped by drug therapies, drugs chosen based on physical and chemical diagnosis. But my problem is not with this. Is with the establishment's mania for prescribing medications to children who's only symptom is being children: restless, hard to concentrate, mischievous, noisy, sometimes rude, jumpy, bouncy... children! This particularly coming from the traditional public schools. I have seen these institutions prescribe Ritalin to perfectly normal children. It is scary!

But of course, I don't mean to be unfriendly, and I apologize if it sounds that way. I can hardly imagine the position you must be in. If I was under the position where I could clearly see there was something wrong with a child under my care and no clear diagnosis to help I may be willing to try anything, but I'd like to think my reason would prevail and I'd try to be objective when choosing to accept a particular treatment (not saying you aren't, just saying what *I* would *try* to do).

|9.24.07 @ 5:32PM|#

There is no test for chronic pain, other than what the patient reports. True, there are physical markers that tells you if someone is in pain, but not to what degree that they are.

Should we tell them "tough shit" since there is no test for their condition?

You're right, similar situatiion, but not quite the same thing. In one case you're talking of children, and of behaviors that are very complex to begin with. In another you are talking about (mostly) adults who can consent and of a relatively simple thing to judge, at least by the patient (pain... less pain... more pain... no pain!) I'm a libertarian, I believe in your freedom to drug yourself anyway you want, for medicinal purposes or just for pleasure. Take whatever makes you feel good. But... a) I advice against using powerful brain altering substances on children on the advice of just plain behaviors and b) I repudiate organizations that force parents to do so.

Fluffy|9.24.07 @ 6:04PM|#

Here's my take on this:

You have to remember that this all takes place in the same culture that criminalizes the taking of drugs for pleasure, and for personal enhancement [i.e. steroids].

The only context in which we are willing to accept/allow people to enhance themselves or their enjoyment by taking a pill is medical. Everything else outrages the puritans and is therefore verboten.

That means that in order to make drugs available for people who really only want to be a little less shy, the people dispensing the drugs HAVE TO call it a pathology. If it's a pathology, it's OK to take the drug. If it's just to improve your social abilities, it's an abuse.

|9.24.07 @ 6:16PM|#

Thank God oppositional defiant disorder hadn't been invented yet when I was a teenager. No snark there; I'm entirely serious.

ADHD, right here!

|9.24.07 @ 7:11PM|#

Precisely my point! You don't know what's going on with your daughter's brain, why would you subject her to drugs that may only complicate matters? What if she really is special and has special potentials that any of the currently overprescribed medicines is going to kill. If current medical knowledge is not enough to treat her, don't treat her just to do something, that's quackery.

That's a very broad brush. No one will deny that psychaitric medication is largely trial and error, due to the limitations of the testing. Not the best way in an ideal world, but there's a shortage of those right now.

I seriously doubt that trying a mainstream medication will "kill" a special property of my daughter's personality. But if a medication can make a difference in the quality of her life, and that is the measure I am using, so much the better.

Now, all that is tempered with what side effects there will be. TANSTAAFL. But if it can make the differnce between her having a sub-par, mediocre life, to an happy and productive one, that's not a tough decision.

There are, close to me, difficult children (not mine, frankly... they are perfect :) ). And at least one of these has been greatly helped by drug therapies, drugs chosen based on physical and chemical diagnosis. But my problem is not with this. Is with the establishment's mania for prescribing medications to children who's only symptom is being children: restless, hard to concentrate, mischievous, noisy, sometimes rude, jumpy, bouncy... children! This particularly coming from the traditional public schools. I have seen these institutions prescribe Ritalin to perfectly normal children. It is scary!

Agreed. But god knows I would have benefited from it. Would have saved me a lot of trouble later in life.

But of course, I don't mean to be unfriendly, and I apologize if it sounds that way. I can hardly imagine the position you must be in. If I was under the position where I could clearly see there was something wrong with a child under my care and no clear diagnosis to help I may be willing to try anything, but I'd like to think my reason would prevail and I'd try to be objective when choosing to accept a particular treatment (not saying you aren't, just saying what *I* would *try* to do).

Fair enough. Medication is not our first option, but it certainly is on the table.

|9.24.07 @ 7:34PM|#

"Cognitive Behavioral Group Therapy was shown to be as good as (and sometimes better) than psychotropic medications for Social Phobia."

Or I could just take my fucking Zoloft and feel fine. 10 seconds to take a pill vs. some kind of touchy huggy group bullshit? I'm sticking with the pill.

|9.24.07 @ 8:36PM|#

REAL 'MERICANS ARE LOUD AND END ALL SENTENCES WITH EXCLAMATION POINTS LIKE THIS! THEY EVEN SHOUT ON THE INTERNET TO MAKE SURE EVERYONE IS LISTENING! PEOPLE WHO CAN STAND TO BE ALONE FOR MORE THAN THREE MINUTES ARE ABNORMAL AND MUST BE MEDICATED! SELF-REFLECTION IS MORBID! QUIET MEDITATION IS FOR FAGGOTS!

EVERY SECOND OF EVERY DAY OF YOUR LIFE YOU MUST BE SURROUNDED BY LOUD PEOPLE AND LOUD THINGS AND BRIGHT COLORS! YOU MUST HAVE 592 CLOSE FRIENDS, 12 OF WHOM YOU MUST BE TALKING TO SIMULTANEOUSLY AT ANY GIVEN MOMENT! GOT THAT?! GREAT! BECAUSE THIS IS BORING ALREADY! LET'S PARTY!

|9.24.07 @ 9:00PM|#

Thank God oppositional defiant disorder hadn't been invented yet when I was a teenager. No snark there; I'm entirely serious.

yOU'RE WELCOME, jENNIFER. nOW STOP TAKING mY nAME IN VAIN, OR i'LL GIVE YOU EARLY MENOPAUSE.

|9.24.07 @ 10:26PM|#

I really do have Social Anxiety/Phobia. It is REAL, and spectacular.

Treatment should be a choice, of course. I choose no treatment, and have a difficult time interacting at all with the public or leaving the house.

It makes work impossible and got in the way of going to the 7 colleges I attended over the last decade.

I think it is probably overdiagnosed. But it's a real thing.

What's funny is most of the people who don't think social anxiety exists are probably the same people who wonder "what's wrong" with me.

|9.25.07 @ 9:45AM|#

John cjaxson the 3rd,

I lost the first 35 years of my life to this. Within a week on Lexapro I was a completely different person. I was really hesitant too, but I would really recommend at least seriously looking into other people's results.

KLF|9.25.07 @ 10:39AM|#

First of all, I would like to say that I found your take on Lane's piece original and insightful. It is true that in the case of psychological illnesses, there are no objective physical tests that can determine if a person has illness X or not. However, I do not think this fact excludes the DSM from being an invaluable resource for both patients and doctors. The truth is, right now the DSM is the closest thing mental health professionals have to x-rays and blood tests. Although I do think psychiatrists should have the freedom to prescribe drugs as they see fit, the DSM can help in determining if drugs are the best course of action, especially since so many psychoactive drugs have potentially harmful side effects that patients may not be aware of. The DSM has come a long way from it's beginnings in Freudian theory of questionable scientific validity, and it would be of great value to everyone if it were to continue to be refined to reflect the growing scientific knowledge of mental illness and the brain. Maybe someday in the future a quick brain scan will tell doctors all they need to know about what mental illness a patient has, but until then the DSM is all we have.

Robert|9.25.07 @ 5:13PM|#

"The only context in which we are willing to accept/allow people to enhance themselves or their enjoyment by taking a pill is medical. Everything else outrages the puritans and is therefore verboten."

Striking counterexample: birth control pills.

Rob Findlay|10.1.07 @ 9:15AM|#

Perhaps we could all agree that for some people (perhaps those with relatively mild shyness) the best solution is self-development and socialising; for people who are more shy than that, face-to-face therapy or online CBT might be better; and then there are some people whose anxiety is much greater and pharmaceuticals may be appropriate?