Before you sell a drug, sell the disease

 

Evanston, IL, USA. What's wrong with being shy? Just when and how did bashfulness and other ordinary human behaviors in children and adults become psychiatric disorders? What is the inside story on how the DSM got to be what it is? 

 

And is it really necessary to prescribe such powerful and potentially dangerous drugs?

 

How did everything become so medicalized?

 

Christopher Lane, a scholar at Northwestern University asks those questions in a new book that offers a behind-the-scenes account of what really happened and why. Lane documents the work of a small group of leading psychiatrists who met behind closed doors in the 1970s. They literally rewrote the book on their profession.

 

Their work turned a thin, spiral-bound handbook into a major desktop resource with a substantially expanded number of diagnoses called The Diagnostic and Statistical Manual of Mental Disorders (DSM).

 

Lane chronicles what he calls the "highly unscientific and often arbitrary way" in which widespread revisions were made to the DSM, a publication known as the bible of psychiatry. It is consulted on a regular basis by insurance companies, courts, prisons and schools, as well as by physicians and mental health workers.

 

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Shyness: How Normal Behavior Became a Sickness. Christopher Lane. Yale University Press, October 2007. ISBN-10: 0300124465. ISBN-13: 978-0300124460. Hardcover: 272 pages. Index.

 

|  Introduction: Bashful No More (PDF)  | 

|  Index (PDF)  | 

 

Radio Interview with Christopher Lane (KUOW Seattle), 1 Nov 2007, skip to 6 min. mark)

 

|  RealAudio  |  MP3  | 

 

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Lane had unprecedented access to the American Psychiatric Association archives and previously classified memos from drug company executives. He unearthed the  — at times scant — scientific justifications and often preposterous rationales for change. Literally hundreds of conditions (shyness, among them) are now defined as psychiatric disorders and considered treatable with drugs.

 

Long-standing disagreements within the profession set the preconditions for these changes, and Lane assesses who has gained and what’s been lost in the process of medicalizing emotions. Lane argues that psychiatry has constructed a façade of objectivity and severely critiques the research findings used to construct a revolution in psychiatry.

 

The author pictures (and documents) a profession riddled with backbiting and jockeying. Even more troubling, he finds a profession increasingly beholden to its corporate sponsors. Lane views the DSM as a windfall for the pharmaceutical industry and a massive conflict of interest for psychiatry at large.

 

"The number of mental disorders that children and adults in the general population might exhibit leaped from 180 in 1968 to more than 350 in 1994," notes Lane, questioning the rationale for the changes, and whether all of them were necessary and suitably precise.

 

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Adam Phillips, psychoanalyst and author of Side-Effects, says Shyness is "… a riveting book about how certain so-called illnesses are complex cultural artifacts and certain so-called doctors are casting spells called diagnoses."

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Lane uses Social Anxiety Disorder (SAD) — at first called social phobia — as the lens for his analysis, tracing the path of American psychiatry's extraordinary shift in the last 30 years from a psychoanalytic orientation relying on talk therapy to an uncritical reliance on partial research results. Noting the current emphasis on neuroscience and drugs, Lane questions the motivation and selective use of evidence behind much of psychiatric practice.

 

Psychiatrists insist that the line between ordinary shyness and SAD is sharply defined, but Lane points to psychiatric literature that repeatedly confuses them, putting patients at risk of over–diagnosis and unnecessary, sometimes harmful, treatment. He draws on previously neglected letters and memos written by the framers of the new disorders to argue that DSM revisions to social phobia or social anxiety disorder placed the diagnostic bar too low.

 

According to Lane, social anxiety has been turned into a mental illness common enough to be considered, according to recent studies, third only to alcoholism and major depression. The DSM continues to stipulate that SAD must be "impairing" for a diagnosis to occur. The problem, Lane argues, is that DSM-defined the symptoms of impairment in 1980 to include:

By 1987 the DSM had removed the key phrase "a compelling desire to avoid," requiring instead only "marked distress," and signs of that could include concern about saying the wrong thing. "Impairment became something largely in the eye of the beholder, and anticipated embarrassment was enough to meet the diagnostic threshold," says Lane.

 

"That's a ridiculous way to assess a serious mental disorder, with implications for the way we also view childhood traits and development," Lane adds. "But that didn't stop SAD from becoming what Psychology Today dubbed 'the disorder of the 1990s.'"

 

In addition to providing extensive documentation from the American Psychiatric Association archives, Lane includes previously confidential material from the drug companies themselves that present a worrisome history of the marketing of antidepressants and how information about side-effects and withdrawal symptoms were withheld from the public.

 

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In 1996, Paxil came into the marketplace despite poor performance and early signs of side effects in clinical trials. The drug's makers earlier had considered shelving it because of the problems involved. Lane presents a memo circulated among drug company executives indicating that a lot of information about the drug's poor track record has been withheld from public view.

 

In 1999, Paxil became the first drug approved by the Food and Drug Administration for treating "social anxiety disorder". However, its makers launched a $92 million awareness campaign on the theme "Imagine Being Allergic to People." This and other advertising campaigns helped change the way Americans thought about anxiety and its treatment.

 

A product director for the drug told Advertising Age magazine that "Every marketer's dream is to find an unidentified or unknown market and develop it. That's what we were able to do with social anxiety disorder." In 2001, with 25 million new prescriptions written for Paxil, the drug's U.S. sales alone increased by 18 percent from the year before.

 

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Harold J. Cook, of the Wellcome Trust Centre for the History of Medicine at UCL (London), says “This is not only an important account of the creation of a modern disease and its treatment, it is an explosive indictment of a system that is too simply materialist in both philosophy and behavior.” 

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Christopher Lane invited psychiatrists and pharmacologists to review his book, particularly the chapter on rebound syndrome. That term refers to a boomerang effect experienced by some patients on discontinuing Paxil that is more intense and dangerous than the turmoil that caused them to take the drug in the first place.

 

In examining the American Psychiatric Association archives, Lane — who argues that psychiatry is using drugs with poor track records to treat growing numbers of normal human emotions — even came across a proposal to establish "chronic complaint disorder," in which people moan about the weather, taxes or the previous night's racetrack results.

 

"It might be funny," he says, save for the fact that the DSM's next edition, due to be completed in 2011, is likely to establish new categories for apathy, compulsive buying, Internet addiction, binge-eating and compulsive sexual behavior.

 

Don't look for road rage, however. It's already in the DSM, under Intermittent Explosive Disorder (IED).

 

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) has undergone several revisions. The most current major update to the manual was published in 1994 and describes what are termed mental disorders. The current edition is slightly revised with text additions (DSM-IV, Text Revision) and available on the the DSM-IV-TR web site. 

 

The DSM is non-theoretical and does not offer information on causes or treatments. It contains a listing of psychiatric disorders, diagnostic codes, information on the prevalence of each disorder, and diagnostic criteria.

 

The Manual is used by mental health professionals for a variety of purposes, such as clinical practice, research, and educational purposes. Clinicians also use the DMS-IV to classify patients for billing purposes, since the government and many insurance carriers require a specific diagnosis in order to approve payment for treatment.

 

Planning is currently underway for DSM-V, scheduled for publication in 2011, with more information available at the APA's "DSM-V Prelude" website. The APA Steering Commitee says it open to suggestions for revision and provides a Suggestions for DSM-V web page at the APA's "DSM-V Prelude" website. 

 

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Christopher Lane is Herman and Beulah Pearce Miller Research Professor, Northwestern University, and the recipient of a Guggenheim Fellowship to study psychopharmacology and ethics. Lane previously directed a psychoanalytic studies program in the psychiatry department at Emory University. He is the author of many essays and several books on psychoanalysis, psychiatry, and culture, including Hatred and Civility: The Antisocial Life in Victorian England.

 

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Also see the related TS-Si.org article, Medicalized: Shaping Our Perceptions Of Illness.

 

 

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