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There is a great deal that's interesting in this book. Chapter one contains an informative history of, "The Hundred Year's War over Anxiety". Chapters two and three provide a great account of the inside wars that gave rise to the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-IIIR and DSM-IV). Chapter four is a clear and somewhat shocking history of how the drug company SmithKlineBeecham remarketed the inferior depression drug Paxil as treatment for social phobia. On the other hand Chapter five, "The Rebound Syndrome", is a rather loose and unconvincing survey of the perils of withdrawal from the new anti-depressives. And Chapter six attempts to support the idea of a backlash against these medications with overly-long summaries of some recent and good fiction.
I am going to take Lane at his word, supported by the book's title, that his main concern is that the new DSM metamorphosed normal behaviors into sicknesses, that shyness is a good example of this phenomenon and that this is a bad thing.
The tale begins with the DSM. It is a familiar story that in the mid 1970s the American Psychiatric Association selected psychiatrist Robert Spitzer to lead a panel that would re-write the diagnostic manual that classifies mental disorders, then called the DSM II (1968). By 1994, the new DSM IV had increased the number of disorder categories from 182 to over 350. Lane quotes a statistic that this definitional reorganization resulted in a thousand fold increase in cases of depression alone (43). On this point I would have liked to have read how Lane would consider this different from similar results when the thresholds for hypertension or excessive cholesterol have been adjusted. In any case Lane has unearthed a great deal about the internal battles and personality conflicts involved in this process, and it's an interesting story that's worthy of expansion into a small book unto itself.
What is Lane's case against the new DSM? Spitzer's claim is that the old DSM was theory laden with psychoanalytic terms and assumptions to the point that it was difficult to diagnose a disorder without committing oneself to some variant of Freudianism. The classic example is the diagnosis of anxiety neurosis that included the technical concept of repression. The idea of the DSM II, IIIR and IV was to classify problems by means of symptoms rather than causes, thus rendering them theory neutral. What's Lane's problem with this ideal?
First, he considers the exclusion of the term "neurosis" from the manual to be a form of anti-Freudian prejudice. Lane quotes Spitzer objecting that the term has "psychoanalytic meaning" (51), with the implication that he had unearthed evidence of prejudice. From Spitzer's standpoint calling persistent anxious behaviors evidence of "neurosis" is the equivalent of calling them evidence of "Zoloft deprivation". The diagnosis itself directs the treatment. Lane makes a good case with interesting historical research that Spitzer and cohorts did not look kindly upon psychodynamic therapies, and that this negative view was a prejudice rather than a scientific conclusion. But he does not make his case that these imperfect motives negatively affected the results of Spitzer's stated program for a theory-neutral DSM.
Lane's second criticism is that the new DSM contains disorders that are not worthy of psychiatric intervention. This is where Lane ties shyness into his central critique of the Spitzer program. His discussion of the messy process of sorting out "anxiety neurosis", "social phobia", "agoraphobia", "panic disorder", "introverted personality", "avoidant personality disorder", "schizoid personality", "social anxiety disorder" and "shyness" is fascinating. But it's not as scandalous as Lane implies. Classification wars have consequences and are not unique to the psychological sciences. Recall, for example, the recent controversies surrounding the redefinition of the astronomical term "planet" that resulted in the exclusion of the much-beloved-by-school-children "planet", Pluto. In any case, the existence of a sloppy process of creation is not an argument against what was created.
Lane's discussion of the psychiatric worthiness of some of Spitzer's new categories, social phobia (shyness) being the exemplar, skims some issues that a philosopher at least would spend some time on. For example, there was a temptation to identify painful shyness with "introverted personality", a concept that was central to Hans Eysenk's personality classification scheme. The objections were many. First Eysenk's use was purely descriptive, implying nothing negative or in any way debilitating. Second, the risk of using "introverted" as a disorder classification threatened to cast what is merely a "way of being" (quiet as opposed to loud, for example) as a mental illness. Third, if "introversion" was defined as an extreme of shyness, it would imply a superiority of extroverted people over their quieter counterparts since extroversion has no natural extreme. (Spitzer's reply that manic disorder was an extreme of extroversion seems to allow for an extroverted introvert since surely one could envision a manic introvert. If Spitzer himself were shy he might have proffered that the extreme of extroversion is "character depth deprivation". One could envision a Newsweek cover story documenting a disturbing increase in CDD in the U. S..)
How exactly should a cognitive, emotional or personality trait, introversion or extroversion, for example, become a treatable trait, that is, a situation worthy of professional attention? Lane laments that Spitzer's group did not respect the criteria of "the 4Ds", significant distress, dysfunction, deviance and danger. These criteria make sense for psychoanalysis, which is conceived as a long, painful, costly and personally transforming experience. Lane quotes the psychoanalyst Otto Will approvingly, "I myself would not treat a person because he was 'introverted'" (83) and Lane shares the horror of psychiatrist Sally Satel and philosopher Christina Hoff Sommers that the DSM IV implies that 26% of Americans, ". . . qualified as having a mental illness within a given year." (201) But what's the source of the scandal? Certainly greater than 26% of Americans qualify as having one or more of the physical diseases listed The Merck Manual 18th Edition, which describes everything from runny noses to brain cancer. Satel and Sommers complain that some of the conditions listed in the DSM IV require no professional intervention but the same is true of The Merck Manual. He approves of Satel and Sommers' claim that, "suffering is sometimes edifying" (205) and notes, "We need more professional skeptics like Satel and Sommers …" (202) (These are the authors of One Nation under Therapy who all but accused PTSD veterans of being fakers and girlie-men.) The point however is that with new therapies (behavioral, cognitive and drug) that direct their efforts at symptom relief rather than personal transformation, that are quicker, cheaper and effective, the 4Ds are hardly appropriate. Does Lane object that The Merck Manual includes warts, acne and indigestion?
The subtitle of Lane's book is "How Normal Behavior Became a Sickness." What exactly is Lane's objection to the inclusion of shyness, under the heading of "social phobia" in the DSM? In some instances he objects to the stigmatizing of a normal personality type (78). Ironically, he seems to take such inclusion as implying that there is something wrong, as people, with those who are intensely shy. Perhaps Lane's error is to maintain the old chestnut that a psychological or emotion disorder is in fact a personal defect, a sin of sorts, in a way that a common cold or ALS is not. If this were true then it might make sense to classify and diagnose only those disorders that are unequivocally serious. But, of course, it is not true. The alternative is to look at what the DSM IV categorizes as sometimes horrible and sometimes annoying but in no way a reflection upon personal character. In the latter case one could leave it to the sufferer as to whether he or she will be treated.
My own view is that shyness, as a self-reflective way of experiencing life, contains positive potentials that are most often ignored. But still the common phrase "painfully shy" is not an accident. Shyness is very often painful. The pain is surely not that of clinical depression, but neither does a skin rash feel like a pinched nerve at C-6,7. Lane is working under a top-down model in which the mental health profession determines which patient discomforts deserve its attention. In addition, he does not address the very restricted availability of psychodynamic therapies in comparison to the time and cost of generic Zoloft or the efficacy of the two combined. In resting the profession's manual from the grip of one therapeutic tradition only, perhaps the greatest effect of Spitzer and company's work has been to empower the patient to achieve the care he or she desires and free up the practitioners to provide a wider range of options.
While I do not think Lane makes his case against the DSM IV or against its inclusion of social phobia, I recommend this book as a thought-provoking and informative read.
© 2008 John D. Mullen
John D. Mullen is Professor of Philosophy at Dowling College in Oakdale, New York. He is the author of Hard Thinking: The Reintroduction of Logic into Everyday Life, co-author with Byron M. Roth of Decision Making: Its Logic and Practice, and the author of the widely read Kierkegaard's Philosophy: Self-Deception and Cowardice in the Present Age.
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