Are We Overdiagnosing Psychological Disorders?

In recent decades, psychologists and psychiatrists have expanded the list of psychological disorders and slackened the criteria for diagnosing them. In Shyness: How Normal Behavior Became a Sickness (Yale University Press, 2007), Christopher Lane questions this decision. He suggests the expansion of the application of psychiatric labels is driven primarily by drug companies, but also by an intolerance for personality differences. Even while American society preaches cultural diversity, it insists on a large degree of conformity when it comes to personality. According to Lane, nonconforming personality traits that might once have been viewed merely as eccentric and treated as something to be tolerated are now viewed as symptoms of personality disorders that must be controlled with pharmaceuticals . Are we helping people to become more normal and functional, or are we forcing them to fit a too-narrow mold?

These are fascinating questions, but unfortunately Shyness is dryly written and lacks clear focus. Too much time is spent in some areas: the book contains a lengthy section discussing literature and movies that raise questions about our current culture of psychology, which is included because the author is, in fact, a literary critic and not a psychiatrist or psychologist. Not enough time is spent in other areas: the reader learns very little about the side effects of drugs other than Paxil. Although it is important to the story of how “shyness became a sickness,” too much detail is expended on the rivalry between the different schools of psychology. This is an important book, but Lane may not be the right person to write it. It would have been preferable if a book such as this had been written not by a literary critic, but by one of the psychiatrists or psychologists who seemed to have concerns about the way the DSM-III was produced.

When the DSM-III was published in 1980, it included 122 (yes, 122) new psychiatric disorders; some of the criteria for diagnosing these disorders included descriptions of behavior previously considered normal. What happened? Christopher Lane uses shyness as his primary example and describes how it was transformed into a psychological disorder against opposition and with support from drug companies that stood to profit. Although he speaks specifically of what became social anxiety disorder or social phobia (the term originally considered was “introverted disorder”), the book raises serious concerns about the entire process of forming the DSM and the many new disorders included. As one psychiatrist is quoted as saying, “I think the majority of us recognized that the amount of good, solid evidence upon which we were making our decisions was pretty modest.” Another said, “I couldn’t believe my eyes — in some cases, the people revising the DSM-III were making a mental illness out of adaptive behaviors.” One quipped that the manual might have been better titled “The Emperors’ New Jockstrap.”

Approval for inclusion of many disorders in DSM-III, says the author (as well as some psychiatrists he quotes), depended in part on whether or not a drug existed to treat them. In other words, ADHD didn’t exist (at least in name) until Ritalin did; and social anxiety disorder didn’t exist (at least in name) until the drugs to treat it did. Even after publication of the DSM-III, many of these disorders did not become well known or frequently diagnosed until drug companies conducted extensive “awareness campaigns,” often under cover of a different organization’s name. When in 1997, the FDA relaxed the rules to allow direct marketing of pharmaceuticals to consumers, spending on such advertisements rose from $595 million to $2.5 billion in just three years as companies worked to “expand the market” for their drugs.

Although Lane admits some people may be helped by these drugs, he thinks the line between personality and disorder has been blurred and that the definitions of many disorders have been expanded to include normal behaviors, so that many people who would, on the whole, be better (or at least no worse) off without drugs end up using them. “The unavoidable conclusion,” opines the author, “is that we’ve narrowed healthy behavior so dramatically that our quirks and eccentricities — the normal emotional range — have become problems we fear and expect drugs to fix…The sad consequence is a vast, perhaps unrecoverable, loss of emotional range.” If this seems an exaggeration, consider that according to Kessler, one of the major orchestrators of the DSM, “about half of Americans will meet the criteria for a DSM-IV disorder at sometime in their life.” If we broaden the definition of disorder to include half of the population, there is not only a danger that we will end up enforcing an unrealistic social conformity, expecting people always to be “on” and “up” and “out there,” but that people who are truly suffering from more than mild forms of anxiety and depression may get short shrift.

One major change in the DSM-III was a mere matter of semantics, but words have great power. The DSM stopped talking about “paranoid reactions” or “anxious reactions” or “schizophrenic reactions” and started talking about “paranoia,” “social phobia” and “schizophrenia.” This had the effect of shifting the characterization of illnesses “by the number and intensity of episodes” to seeing them as being like “permanent, even innate conditions. . . Illness started to define patients rather than appearing as simply facets of their personality, and psychiatrists found it increasingly difficult to assess the full extent of their patients’ unease.” That is, when patients are defined by their diagnosis and treated with drugs, very often the more complicated factors also affecting behavior are overlooked. “Doubtless it is easier to accept that our suffering derives from faulty neurotransmitters than it is to concede that numerous factors–psychological, biological, social, and environmental–influence our states of mind.” Lane should have added “spiritual” to that list, and the spiritual element is a glaring omission from the book.

Lane talks a great deal about Paxil: how it affects the brain, what its side-effects are, why it doesn’t improve symptoms in as many as 1 in 5 cases (still, that means it improves them in 4 in 5 !), and why so many people experience worse problems when they finally go off the medication than they did before they ever went on it. Unfortunately, Lane does not discuss other medications in detail, and the reader is left to wonder if he has a private axe to grind with Paxil. In railing against overprescription of medication, Lane also does not consider Americans’ long history of self-medication for depression and anxiety. Are we perhaps merely replacing this erratic self-medication (primarily via alcohol) with the more accurate, controlled, and regulated medication of prescription drugs? Or are we merely throwing monitored, prescribed medication on top of unmonitored, self-medication?

The author’s solution to the perceived problem of overdiagnosis is not to scratch these disorders or to ignore the existence of severe problems, but rather to tighten the criteria for diagnosing these disorders. Unfortunately, he says, many psychiatrist and drug companies want to see these criteria relaxed, not tightened, to include more people in the diagnosis and to sell more drugs. Another part of Lane’s solution is social: western society should increase its tolerance for introverts and for shy, modest, and bashful behavior.

Lane leaves the reader with a considerable number of concerns. Many of the symptoms listed for social anxiety order used to be simply called shyness. The level of shyness described in the diagnostic criteria for social anxiety disorder is experienced, studies estimate, by upwards to 20% of the population. Does 1/5th of the population really have a “phobia”? Why are people in the west seemingly so disturbed by introversion, even in its non-disordered forms? Do drug companies have too much influence on the creation of criteria for disorders? If the reader can plod through the dryer parts of this book, he or she will be given much food for thought.

If this topic interests you, you may want to read “Introverts Are Not Idiots.”