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AUGUST 2, 1999 ISSUE SELLING SHYNESS Selling Shyness How doctors and drug companies
created the "social phobia" epidemic. Do you have trouble speaking in public?
Do you have a hard time making friends?
Are you shy?
If so, researchers at MCP Hahnemann University in Philadelphia
want you to contact them about enrolling in an on-going
research/treatment program funded by the National Institute of
Mental Health. While you may long have considered shyness to be just
another element of your personality, it seems that medical science
has decided that this trait might actually be the expression of a
chronic mental disorder. And you are far from alone. According to
the American Psychiatric Association, a veritable epide mic of
morbid reticence is under way. The APA estimates that one in eight
Americans will, at some point in his or her life, fall prey to
social anxiety disorder - also known as social phobia. Social
phobia, doctors say, can reduce even the most flamboyant personality
to a trembling shut-in. No less a showman than Donny Osmond has
written a memoir of his struggle with an uncontrollable fear of
public spaces. Laurence Olivier and King George VI are also thought
to have been social phobics. If the one-in-eig ht figure is
correct,social phobia is the third most common mental illness, after
depression and alcoholism.
A collection of doctors, corporations, and ordinary citizens is
mobilizing to sound the alarm about this health menace - spreading
the bad news that social phobia is rampant, along with the good news
that it is now treatable with medication. In mid-Ma y, the
pharmaceutical maker SmithKline Beecham received FDA approval to
market Paxil, an anti-depressant similar to Prozac, as a treatment
for the disorder. Concurrently, a coalition of nonprofit groups
(with financial support from SmithKline) launched a public awareness
campaign about the condition, built around the clever slogan,
"Imagine Being Allergic to People." Articles on the nightmare of
social phobia have been popping up in newspapers around the country,
and, in mid-June, the disorder officially hit the big time, with a
cover story in U.S. News & World Report.
Social phobia, in short, is what physicians sometimes call a "hot
diagnosis" - this year's version of the attention deficit disorder
(ADD) boom that took off a few years ago. As with ADD, the research
and marketing of social phobia - an affliction tha t barely
registered in the professional literature a decade ago - illustrate
how certain personality traits once considered troubling but
"normal" can be recast as symptoms of a treatable medical condition.
This process does, of course, have an upside. Many people
previously debilitated by their symptoms have benefited from
increased awareness of depression and ADD and the medications now
available to treat them. But the sudden surge of social phobia is
also a reminder that disorders don't just happen. Definitions of
illness and health do not belong solely to the white-coated realm of
pure science . They are social, cultural, and economic phenomena as
well. They are not invented, exactly, but coaxed and shaped into
public acceptability by a cadre of medical researchers, mental
health practitioners, pharmaceutical manufacturers, and advocacy
groups - each operating from varying degrees of ambition, scientific
knowledge, opportunism, and good intentions. This is often a long,
arduous process. Even in America, where we're perpetually in search
of new maladies to explain our discontent and depersonaliz e our
behavior, it can take years for the populace to be taught that what
was long thought to be a behavioral quirk is in fact a mental
illness. Thus, the rise of social phobia offers a glimpse not so
much at the anatomy of a specific illness as at the st ill
inherently subjective nature of psychiatric medicine and the
cultural forces that help draw the boundary.between what we are told
to think of as normal and what we are told to consider pathological.
"Our ancestors were so stupid and short-sighted tha t when
the first reformers came along and offered to deliver them from
those horrible emotions, they wouldn't have anything to do with
them."
A disorder like social phobia does not spontaneously arise, fully
formed, from some fevered recess of the human brain. Before it can
make its proper debut, teams of researchers and psychiatrists,
working with perhaps only a handful of similar symptoms found in a
scattering of patients, must conceptualize the condition, define it,
and estimate what percentage of the population may be suffering from
it. This last part is especially important because, for a mental
illness to really generate buzz in the c linical and corporate
communities, it needs to affect a lot of people.
At first glance, social phobia would seem to afflict everyone.
According to a pamphlet put out by the Anxiety Disorders Association
of America (ADAA), "The key element of social phobia is extreme
anxiety about being judged by others or behaving in a w ay that
might cause embarrassment or ridicule." In fact, some researchers
believe that the roots of social phobia can be traced to a time when
being judged and rejected by one's tribe meant banishment or death.
Performance anxiety, in particular, seems to fit this scenario.
(What was once termed "stage fright" is now classified as the most
common form of social phobia). When you are standing in front of a
group, preparing to speak, sing, dance, or play the accordion,
members of the audience are judging yo u - especially if they've
paid good money to be there. And, if such performances are in any
way tied to your livelihood, there is the real possibility that
failure could ultimately damage more than your pride. On an even
more primitive level, we are hardw ired to get nervous when someone
- or something - is staring at us. Predators stare at their prey
before devouring it. Staring matches are a way to establish
hierarchies within social units, both human and primate. From this
perspective, people who don't get freaked out when being eyeballed
would seem to be the odd birds.
Indeed, psychiatry was initially reluctant to define social
phobia in a way that would encompass vast numbers of patients. The
disorder didn't officially enter the psychiatric lexico n until
1980, when it was included in the third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM), the APA's
periodically updated - and ever-expanding - catalog of maladies,
codifying everything from schizophrenia to kleptomania. While the
majority of conditions are relatively noncontroversial, the DSM is a
notoriously plastic document, only somewhat more insulated from
social trends and ideological fashion than, say, your average weekly
journal of opinion. For example, intrashrin k warfare raged for
years over whether to remove homosexuality from the list of
sexuality-related maladies. (It was omitted from the 1974 edition of
the DSM.) For patients and doctors, what's critical about the DSM is
that, without an entry and code numbe r in the manual (social
phobia's is 300.23), a condition will not be covered by health
insurers. Thus, the APA has more than a little incentive to codify
as many behavioral mutations as it plausibly can. But the DSM-III,
as the 1980 edition is affectionat ely known, had very exacting
standards for what constituted social phobia. First, the definition
focused on patients with a fear of only one activity, such as
writing, eating, or speaking in public; people with multiple or
generalized social anxiety were thought to have a different
condition altogether. Moreover, according to the DSM-III, it was not
sufficient that a person fear a situation; to qualify, the fear had
to compel one to avoid such a situation altogether. "The disorder,"
noted the DSM-III, "is apparently relatively rare."
The mid-'80s, however, marked a turning point in academic
thinking about social phobia. In the early part of the decade,
research indicated that only two to three percent of the population
grappled with the problem; by the early '90s, observed prevale nce
rates were pushing double digits.
Mental health advocates attribute this shift to a landmark study
published in July 1985 by Michael R. Liebowitz, director of the
Anxiety Disorders Clinic of the New York State Psychiatric
Institute. In an article titled "Social Phobia: Review of a Neg
lected Anxiety Disorder," Liebowitz bemoaned the dearth of data on
the malady and the lack of consensus about its diagnostic criteria
and prevalence. He also criticized the DSM-III's limited definition,
which, as he explains today, "narrowed and marginali zed" the
disorder, unnecessarily labeling those "with more severe general
shyness" as having avoidant personality disorder (a completely
different breed of illness that, as the 1985 study noted, was
dismissed as largely unresponsive to "pharmacological in
terventions").
Liebowitz's article caused the medical community to take another
look at social phobia, says Jerilyn Ross, president of the ADAA:
"People were clamoring for information." And the more researchers
explored the disorder, the more the psyc hiatric community gave it
recognition. The first sign of change came when the APA loosened the
definition of social phobia. In 1987, the association published a
revised version of the DSM-III (dubbed, cleverly enough, the
DSM-III-R). Liebowitz was on the advisory panel charged with
updating the entry on social phobia. In light of additional
analysis, he explains, the committee decided to include a
generalized subtype of the condition. This addition, combined with
the use of more comprehensive screening qu estionnaires, led to the
subsequent rise in measured rates of the disorder's prevalence in
the general population, says Liebowitz.
Perhaps even more significant, however, was the panel's decision
to remove the phrase "a compelling desire to avoid" from the
diagnostic criteria. From that point on, a person could be
classified socially phobic if his anxiety simply caused him "marke d
distress." When asked about this crucial semantic shift, Liebowitz
explains, "I think the issue there is that there are people who
fight their way through difficult situations." These folks wouldn't
meet the strict avoidance test, but they nonetheless e ndure social
situations at "tremendous personal costs." "You don't want to
penalize these people," he says. "You don't want to say that, in
order to meet this definition and get reimbursed for treatment, they
have to stop pushing themselves."
Whatever the rationale, the impact of these diagnostic shifts was
impressive. A study published in the January 1994 Archives of
General Psychiatry put the lifetime prevalence of social phobia
among Americans at a whopping 13 percent - the attention-gr abbing
one-in-eight number now circulating. A later study, published in the
February 1996 issue of the same journal, reported similar
conclusions. Remarking on the dramatic increase in prevalence from
earlier research, this study's authors explained that it was largely
a matter of definition: had they used the DSM-III "avoidance"
standard, the prevalence rate they reported would have dropped to
8.3 percent. Had they stuck with the more limited questionnaires of
earlier studies, the rate would have dropped again to 4.8 percent.
The survey questionnaires themselves invite a broad
interpretation of social phobia. For instance, in the first phase of
a Canadian study published in 1994, people were asked whether, in
certain situations such as "attending soc ial gatherings" or
"speaking to a large audience," they tended to be "much more
nervous," "somewhat more nervous," or "about the same as" other
people. Those answering "much more" or "somewhat more" were then
queried on which situation made them most unco mfortable and asked
to rate the degree to which this had a negative impact on their
lives and the degree to which this disruption "bothered" them.
Response options were "none at all," "a bit," "a moderate amount,"
or "a great deal." (Based on DSM-III-R st andards - "marked
interference or distress" - this survey put the prevalence rate of
social phobia at just over seven percent.)
This survey was conducted by phone - an arrangement hardly
conducive to careful analysis by the interviewers. But these
questions would have been open to major interpretation under any
circumstances. It's human nature to assume that we are less comfor
table or adept at schmoozing, public speaking, interviewing for
jobs, or chatting up the opposite sex than other people are. This is
particularly true during adolescence - which is, incidentally, when
social phobia is said to strike most often. It is the rare,
fortunate ego that has never hidden in the corner at a party,
flubbed a job interview or key business meeting, or missed a shot at
a hot date because of an attack of nerves. From this perspective,
the Canadian questionnaire seems not so much a scien tific gauge of
mental illness as an invitation to share one's "normal" self doubts.
Having run across a number of other equally vague survey models,
I decided to conduct an unscientific poll of my own. I asked some of
my coworkers at TNR to take a short diagnostic test developed by a
psychiatrist at Duke University. Participants were first asked to
rank, on a scale of zero to four, their fear and avoidance of seven
social situations: speaking in public or in front of others, talking
to people in authority, talking to strangers, being embarrassed or
humiliated, being criticized, socia l gatherings, and doing
something while being watched (excluding speaking). Next, they were
to rank the degree to which social situations caused them to
experience blushing, trembling, palpitations, or sweating.
The book from which I pulled the test, Social Phobia, by John R.
Marshall, M.D., cautioned that "there is no absolute score that
indicates social phobia." As a point of comparison, however, it
noted that "patients in a treatment study for social phobia had
pretreatment scores on this scale ranging from 19 to 56." Of the 23
TNR staffers to complete the survey (the rest were presumably too
timid), a sizeable majority scored above 19. Based on these results,
I've recommended that the magazine's benefits m anager explore the
possibility of getting a group discount on Paxil.
"And if ever, by some unlucky chance, anything unpleasant
should somehow happen, why, there's always soma to give you a
holiday from the facts. And there's always soma to calm your a nger,
to reconcile you to your enemies, to make you patient and
long-suffering.... [S]wallow two or three half-gramme tablets, and
there you are."
Without question, it can be much more exciting to be involved in
the research or treatment of a mental d isorder that afflicts 35
million people than one that afflicts, say, two million people. For
one thing, the more victims an illness claims, the more pressure
there is for the government to fund research on that illness.
Currently, there are some 20-plus r esearch projects on social
phobia being funded by the National Institutes of Health. (In 1986,
there was only one.)
But government dollars account for only a sliver of the funding
pie. Presented with a large enough client base, the pharmaceutical
industry will beat a path to your door. Interviewed in a recent New
York Times article, Liebowitz, who moonlights as an industry
consultant, noted that, once the prevalence rate of social phobia
hit eight or nine percent (thanks, in no small part, to the expanded
definition championed by Liebowitz), the drug companies developed a
keen interest in the plight of the socially phobic.
This interest often manifests itself in the form of direct
funding for research. Other times, companies funnel money through
nonprofits such as the APA - whose social phobia website is
supported by SmithKline - and the ADAA. The "Allergic to People" c
ampaign is just one of a host of ADAA projects underwritten by the
pharmaceutical industry, including educational materials,
conferences, websites, outreach programs, and research. On July 19,
the ADAA will hold a press conference to announce the findings of an
economic impact study, underwritten by various drug manufacturers,
that purports to quantify the high cost of anxiety disorders to the
nation's productivity. (Similar studies have been produced for
depression.) Three years ago, to facilitate such j oint ventures,
the ADAA formed a corporate advisory board comprising
representatives from about ten drug firms. The board helps the
association conceptualize and fund various educational projects. The
ADAA's Ross describes the industry's participation in such efforts
as "hands-off, but wonderfully supportive."
Nevertheless, the drug makers and the ADAA can be cagey about
exactly who handles which parts of these projects. For instance, the
"Allergic to People" campaign is being orchestrated by SmithKline's
public relations firm, Cohn & Wolfe Healthcare. Som e of the
firm's work has been pro bono. The rest, according to Ross, was paid
for directly by the pharmaceutical giant. "I purposely do not get
involved. We don't want to know," she explains. SmithKline's Richard
Koenig, however, insists that, for project s like this, the company
simply hands money over to the ADAA to be distributed as the
association sees fit. Ross acknowledges that, because of the ADAA's
advocacy role, the group's ties to the pharmaceutical industry
require her to "walk a fine line." He r basic policy is "to never do
anything that directly promotes or markets drugs or smacks of it."
Even so, drug manufacturers often find ways to leave their
fingerprints on the projects they support. A 1996 ADAA brochure on
social phobia, "supported by an educational grant from SmithKline
Beecham," notes that "[m]edications are usually effective in the
treatment of social phobia and can be used with or without other
treatments." No mention is made of the high "relapse" rates
associated with drug treatment (the number cited most often is 50
percent within six months of stopping medication). And although no
hard data exist to prove that a therapy-drug combination is more
effective, practitioners generally believe this to be the case.
"There is less likely t o be any relapse if a person has had
cognitive behavior therapy," says Ross, who runs her own treatment
center for anxiety disorders. Someone who just takes medication, she
explains, has no understanding of how to cope with stressful
situations that arise down the road.
Of course, even the most disinterested education campaign
benefits drug makers. Increasingly, the industry sees its marketing
aim as peddling a disorder rather than just the pills to treat it.
In The Anti-Depressant Era, David Healy, director of the North Wales
department of psychological medicine at the University of Wales,
notes that "drug companies obviously make drugs, but less obviously
they make views of illnesses. They don't do so by minting new ideas
in pharmaceutical laborat ories, but they selectively reinforce
certain possible views." Anything that focuses the popular mind on a
disorder - including "physician education" campaigns, public
awareness efforts, and newsmagazine cover stories - ultimately helps
a drug company mov e product.
Healy recounts how, during the 1960s, in promoting the
antidepressant amitriptyline, "Merck marketed the concept of
depression by buying and distributing 50,000 copies of [a] book on
recognizing and treating depression in general medical settings." If
doctors could be sensitized to signs of the disorder, the odds of
their perceiving it in patients greatly increased. An example from
more recent years is the industry's funding of a National Screening
Day for social phobia and other anxiety disorders. Th e annual event
- officially sponsored by the ADAA - has grown to include more than
1,600 test sites. The ADAA boasts that, on a recent screening day,
76 percent of participants reported that "anxiety has interfered
with [their] daily lives," while 51 perc ent were prompted to seek
treatment.
In his book, Healy notes a pattern emerging in the field of
psychiatric medicine: a relatively rare mental disorder is known to
exist, a psychotropic drug is found to have an effect on the
disorder, and, subsequently, the rates of diagnosis multiply e
xponentially. He charts this progression in the history of
depression, panic disorder, obsessive-compulsive disorder, and
social phobia. "This is not to say that psychiatrists or drug
companies are just making up mental disorders," says Dr. Carl
Elliott, an associate professor at the University of Minnesota's
Center for Bioethics. "They're out there. But the boundaries are
very fuzzy. And when there's money to be made with a psychoactive
drug, there's suddenly all this interest in making these borders exp
and."
"Yes, 'Everybody's happy nowadays.'... But wouldn't you like
to be free to be happy in some other way, Lenina? In your own way,
for example; not in everybody else's way."
Most mental health professionals stress the enormous difference
between social phobia and run-of-the-mill insecurities. "It's more
than just shyness" has become something of a mantra for the APA. But
trying to differentiate a "mild" case of social phobia from "normal"
shyness is like trying to nail Jell-O to the wall. Ross suggests
that a socially phobic person is one so anxiety-ridden that he
actually avoids certain situations. Not according to the DSM-III-R
(or the DSM-IV, for that matter). Liebowitz, meanwhile, says
everything exists on a sp ectrum. "It's a definitional issue. Social
phobia is severe shyness to the point of real subjective distress or
impairment, where it really begins to interfere with a person's life
or they feel miserable about it."
Thus, the distinction between shyness and mental illness is now
largely a matter of what each individual (or each individual's
doctor) considers "significant distress" and how closely an
individual's perception of her personality conforms with her perc
eption of what it should be. If you are content to live as a hermit,
communicating with the outside world only over the Internet, you are
not socially phobic. If you are a basically gregarious person who
goes to pieces at the prospect of 200 strangers dis secting your
every word during a presentation, you are a candidate for treatment
- assuming, of course, that your fear "bothers" you. The assertion
that social phobia is not "just shyness" suggests a bright dividing
line that simply does not exist. In the ir heart of hearts, most
people know that shyness - no matter how maddening - is not a
disorder. But social phobia, we are warned repeatedly, is something
completely different. It is not normal. If you have it, you need
help. And, if one out of every eigh t Americans is plagued by this
disorder, the odds that you have it are pretty good, aren't they?
Even if you don't, wouldn't it be great to have that extra
pharmacological edge? Science cannot determine the precise point at
which a person's shyness is too "normal" to be affected by drugs.
Medication may have an effect on people across the board, says
Liebowitz. "But it's probably not worth it until someone's at the
point where he's distressed or impaired," he adds
.But, just as the advent of Prozac prompted droves of moderately
angst-ridden yuppies to try to medicate their way to contentment,
there will be more than a few people who see social phobia drugs as
a way to boost their confidence and interpersonal ski lls - the
chemical equivalent of a motivational workshop with Dale Carnegie or
Tony Robbins. Nor does the Prozac experience suggest that we can
necessarily rely on doctors to carefully evaluate each individual
before scribbling out a prescription. In the age of managed care,
much of the appeal of psychopharmacology is that it's quicker,
cheaper, and less labor-intensive than actually spending time with
patients - and hence more likely to be fully covered by insurance.
More and more, psychiatrists are fadi ng from the picture as drug
sales reps "educate" general practitioners and internists on how to
recognize and treat (i.e., medicate) mental disorders.
None of this is to suggest that some people aren't suffering.
Certainly there are those who have a deb ilitating fear of social
interaction. They rarely leave their homes. They cannot attend
school or hold down a job. Dating is an impossibility. But for the
mental health establishment and drug companies to push the notion
that more than 35 million American s are adrift on a sea of morbid
shyness strains the limits of plausibility. More likely, this
"epidemic" represents yet another step in the culture's crusade to
medicalize any trait - physical or behavioral - that does not
measure up to the elusive ideals generated by pop culture,
advertising, and shifting moral and political norms. And the more
people buy into these culturally defined ideals, the less tolerant
we become of those who don't.
"There's definitely a very culturally relative aspect in how
shameful it's seen to be shy," says the University of Minnesota's
Elliott. "People in America seem to regard shyness as a big social
handicap. We write self-help books about overcoming your s hyness -
which strikes my Chinese and Japanese friends as very strange.... In
America, we tend to assume that the natural tendency of people is to
be outgoing." Indeed, one wonders how much of the nation's social
phobia epidemic stems from our growing sen se that everyone should
be aggressive, be assertive, and strive for the limelight. Forget
the life of quiet contemplation. We are a society that glorifies
celebrities and celebrates in-your-face personalities such as Jesse
"The Body" Ventura. For a shot a t their 15 minutes of fame, Jane
and Joe Schmoe are lining up to expose even the most degrading or
banal aspects of their personal lives to public scrutiny via Jerry
Springer, the Internet, and "America's Funniest Home Videos."
Increasingly, we have littl e admiration - or patience - for those
who don't reach out and grab life by the throat. And if we have to
put one-eighth of the population on expensive medication to bring
them into line, then so be it.
"O brave new world that has such people in it."
(Copyright 1999, The New Republic)
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