Are shy people mentally ill?: the DSM and SAD

... because I'm good enough, smart enough, and — doggone it — people like me! ~ Stuart Smalley

I was born the year they first published the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fourth edition as DSM-IV. I was a shy little boy. In fact, I was so shy, instead of wishing the ground would open up and swallow me, I dug my own little foxhole and crouched there for most of my childhood. Little did I know that the majestic architects of the DSM's careful categories and checklists would some day cast concerned looks at trembling little me in my hiding place and see another instance of a treatable social anxiety disorder. Nor could I have imagined how one day pharmaceutical companies would promote the idea that things like diffidence and embarrassment are ameliorable through drug therapy, that by swallowing a little green and white pill I could feel as if I had just aced the Endtime and placed my conquering toe upon the Mount of Olives.

What pill would they prescribe for the timid and empty-headed Georgiana Podsnap of Our Mutual Friend, who is so painfully shy she squeals like a panicky toddler at the prospect of being introduced to strangers?

Oh there's Ma speaking to the man at the piano! Oh there's Ma going up to somebody! Oh I know she's going to bring him to me! Oh please don't, please don't, please don't! Oh keep away, keep away, keep away!' These pious ejaculations Miss Podsnap uttered with her eyes closed, and her head leaning back against the wall. ... 'Oh there's Ma being awful with somebody with a glass in his eye! Oh I know she's going to bring him here! Oh don't bring him, don't bring him! Oh he'll be my partner with his glass in his eye! Oh what shall I do!' This time Georgiana accompanied her ejaculations with taps of her feet upon the floor, and was altogether in quite a desperate condition. (Charles Dickens, Our Mutual Friend, Chapt. 11, Podsnappery)

What about the terribly bashful Edward Ferrars in Sense and Sensibility, with his awkward silences and stiff politesse? What if he were popping Zoloft to make it through high tea with his formidable relations?

Edward Ferrars was not recommended to their good opinion by any peculiar graces of person or address. He was not handsome, and his manners required intimacy to make them pleasing. He was too diffident to do justice to himself; but when his natural shyness was overcome, his behaviour gave every indication of an open, affectionate heart. His understanding was good, and his education had given it solid improvement. But he was neither fitted by abilities nor disposition to answer the wishes of his mother and sister, who longed to see him distinguished - as - they hardly knew what. They wanted him to make a fine figure in the world in some manner or other. His mother wished to interest him in political concerns, to get him into parliament, or to see him connected with some of the great men of the day. Mrs. John Dashwood wished it likewise; but in the mean while, till one of these superior blessings could be attained, it would have quieted her ambition to see him driving a barouche. But Edward had no turn for great men or barouches. All his wishes centred in domestic comfort and the quiet of private life. Fortunately he had a younger brother who was more promising. (Jane Austen, Sense and Sensibility, Chapt. 3)

Fewer Eeyores, more Tiggers

Would we say that Georgiana and Edward, with all their social faults, were mentally ill and in need of medication? For those of us who have no turn for great men or barouches — who would rather stay home with the cat and The Cask of Amontillado than kiss cheeks at a cocktail party — our shyness may be limiting at times. It may be, as some say, merely egotism out of its depth; but it doesn't feel like a disorder. It's more like the way being myopic keeps one from taking up skeet shooting, or being dyslexic makes reading The Faerie Queene an exercise in futility. Life goes on, even if you're not a hotshot Spenser scholar.

Like many other normal human imperfections — stretch marks, baldness, flat feet — shyness is a fact of life you accept, if not embrace. Just as there are many bumptious bigwigs conquering the world on white horses and donning their crowns of laurel, there are also all the little shy people who are modestly content to pluck their bouquets of wallflowers and violets. Of course, introversion can occasionally get in the way of things; but we introverts have our various means of coping: bathroom mirror self-assertion, transcendental meditation, unlisted numbers, pimple cream, tequila.

But it appears that some DSMmers out there would claim I was mentally ill until, somewhere in the dirty bottom of the 1970s, I left my mirror, emerged into the sunshine, and realized that — doggone it — people liked me. Eeyore had turned into Tigger.


Toastmasters or Paxil?

Brian Cox holds a Canada Research Chair in mood and anxiety disorders at the University of Manitoba, so he is probably as qualified as anyone to comment on the health of the timid and insecure. In his review of Christopher Lane's new book, Shyness: how normal behavior became a sickness [1], which appeared in the January 31 issue of the NEJM [2], Cox agrees with Lane that psychiatrists should stop pathologizing and medicating shy children:

I find it interesting that the term "social phobia" has increasingly been replaced by the term "social anxiety disorder" in the official nomenclature. I don't believe that this is purely coincidental. Rather, it seems to me that if a general physician sees someone with a social phobia, the physician may recommend that the patient see a psychologist for behavior therapy, participate in Toastmasters, or use another self-help resource. However, if the same person receives a diagnosis of social anxiety disorder, a term that sounds far more serious, the physician might recommend more aggressive medical attention such as pharmacotherapy.

Shyness is not a "sickness" or a psychopathology, argues Cox, who conducted a study [3] a few years ago which found that many with extreme childhood shyness didn't meet the criteria to be diagnosed with an anxiety or mood disorder. Conversely, half the adults with severe social phobia did not view themselves as very shy when growing up. In his NEJM review, Cox states his conviction that it is important not to view shyness in young people as a form of mental disease requiring medical intervention, thereby potentially damaging their self-esteem and self-confidence. In other words, the kids are all right.

"Is she just shy? Or is it Social Anxiety Disorder?" (Advertisement for Zoloft in The American Journal of Psychiatry, August 2003)

The day I ran across Cox's book review I happened to be reading the 6 December 2007 New York Review of Books, which contains a beautifully written article, Talking back to Prozac [4], by the irreverent Frederick Crews, Professor Emeritus of English, UC Berkeley, and author of The Pooh perplex. Crews discusses three books that are critical of the mental health establishment and its relations with Big Pharma, one of them being Lane's Shyness. Also reviewed are Horwitz and Wakefield's The loss of sadness [5], and the release in paperback of David Healy's well known Let them eat Prozac [6], first published in 2004.

Crews begins with a fascinating anecdote about the 2002 appearance of star football player Ricky Williams on The Oprah Winfry Show. The brawny athlete went before the cameras to spill in a major way. He revealed that he suffered from social anxiety syndrome. Very touching. What didn't show up in the credits, however, was that Williams was a paid shill for Glaxo-SmithKline — not to do anything so flagrant as to tout its own product, Paxil, but simply to do a little "condition branding" by persuading Oprah's gullible glued eyeballs to believe that being "a shy person" could actually be a disorder requiring antidepressant medication.

Crews launches into an acerbic critique of the happy-drug industry. His verdict: "[O]ne thing is certain: the antidepressant makers have exploited our gullibility, obfuscated known risks, and treated the victims of their recklessness with contempt." As for the mental health industry, Crews wants a DSM that is "scientifically respectable; its users, instead of regarding disadvantaged classes as infested with mental illness, will gain an appreciation of socioeconomic reasons for unhappiness; and a brake will be placed on the expensive middle-class hypochondria that the drug companies have so assiduously encouraged and exploited."

These three books point us, as Crews asserts, "toward some uncomfortable insights about American psychiatry and its role within a far from rational health care system." He goes on to suggest the deeper significance of psychiatry's inability to settle on a discrete list of disorders that can remain impervious to fads and fashions. In a perfect storm of hypocrisy, for bureaucratized psychological treatment, and for the pharmaceutical industry that is now deeply enmeshed in it, confusion has its uses.

Now, I understand that there are some who suffer from debilitating fear of social situations and who may need to seek medical help, including drugs that moderate their symptoms. However, the tendency towards untrammelled use of expensive glamour drugs to medicate away what is simply an aspect of the human condition — that looks like the devil's bargain.

Long before Ricky Williams made his public confession on Oprah, an article appeared in The New York Times which made mention of Williams' "shyness syndrome," adding interesting details like the fact that he kept his helmet on during rookie-year media interviews. No indication yet of the money flowing from the stealth marketing Paxil pushers into the football player's bank account. But we are offered this shrewd comment: "[I]t is much easier to turn on the spigots of empathy and attention these days when you can cite a diagnosed imbalance in brain chemistry rather than an eccentricity, a character flaw or an economic disadvantage." Much easier as well to market your designer drug. Successfully hyped by socially anxious celebrities like Williams, Donny Osmond and David Beckham, social anxiety disorder has become a widely recognized "condition." Those who have the money can now buy happiness. Shyness is for losers.

The company accountant is shy and retiring. He's shy a quarter of a million dollars. That's why he's retiring. ~ Milton Berle

References:

1. Lane C. Shyness: how normal behavior became a sickness. New Haven: Yale University Press; 2007.

2. Cox BJ. Shyness: how normal behavior became a sickness [book review]. N Engl J Med. 2008 Jan 31;358(5):539-540.

3. Cox BJ, MacPherson PS, Enns MW. Psychiatric correlates of childhood shyness in a nationally representative sample. Behav Res Ther. 2005 Aug;43(8):1019-27. PMID: 15967173

4. Crews F. Talking back to Prozac. The New York Review of Books. 2008 Dec 6;54(19):10-14.

5. Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. Oxford: Oxford University Press; 2007.

6. Healy D. Let them eat Prozac: the unhealthy relationship between the pharmaceutical industry and depression. New York: New York University Press; 2004.