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Selling Shyness

How doctors and drug companies created the "social phobia" epidemic.
by Michelle Cottle

Article art image "Fortunate boys!" said the Controller."No pains have been spared to make your lives emotionally easy - to preserve you, so far as that is possible, from having emotions at all."
Aldous Huxley, Brave New World

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)