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GP
First of all, please introduce yourself to the Italian public: your latest
book has not been translated yet and not everybody knows about the
theories you expressed in it about shyness and sickness.
CL Well, I’m a London-born
scholar now based in Chicago. I was educated and trained in England as a
specialist of Victorian literature, but ever since I began my career in my
twenties (I’m now in my early forties) I’ve been fascinated by
nineteenth-century psychology and psychoanalysis. All four of my books
have looked at Victorian fiction through the lens of such psychological
theories. In the past few years, as “Shyness” hopefully demonstrates, I’ve
broadened my interests to include intellectual history. What I’m trying to
do, then, is use the topic of “shyness” to document major changes in
American and European psychiatry, particularly the shift in the last three
decades from talk-related therapy to neuropsychiatry and its emphasis on
medication.
GP
Why did you become interested in shyness and why did you write your latest
book, “SHYNESS: How Normal Behavior Became A Sickness”?
CL
After I finished a book on antisocial behavior in Victorian literature and
culture (Hatred and Civility, 2004), I wanted to examine what
happened to mavericks, the idiosyncratic, and, indeed, the shy in the 20th
and 21st centuries. When I asked several leading psychiatrists
about this, invariably they hinted that these people had been medicated. I
grew concerned that medication was being used to eradicate key aspects of
our humanity—emotions and behavioral traits that may be extreme, but that
remain vital parts of us we can’t simply dismiss or medicate away. Above
all, who was determining which emotions and behaviors could stay and which
should go?
Having reviewed so much of the psychiatric literature on the various
personality, anxiety, and mood disorders, I’ve grown far more concerned
about this question and underlying trend. Contemporary psychiatry is in
many respects deeply conservative, conformist, and narrow in what it views
as “normal behavior,” a category that has shrunk quite dramatically in
recent years, so that fewer and fewer of us manage to squeeze into it.
Indeed, growing numbers of us are persuaded that there’s something
fundamentally wrong with us that drugs can and must fix. That trend
frankly worries me. While it’s true that many people are anxious and
concerned about how they fit in and how the world is changing, medication
often is not the solution, but actually something that can make things a
great deal worse—by introducing a large number of troubling side effects,
for instance, and by not addressing the underlying issues that are causing
such anxiety in the first place.
GP
How is the book selling and where has it encountered the greatest interest
and success? According to the feedback you surely receive, could you tell
us if your readers are mostly doctors and psychiatrists or the general
public?
CL My editor tells me the
book is selling very well (several thousand copies in the first months
since release). The reviews generally have been very positive, too, with
most recognizing that the book brings to light an important and largely
ignored chapter of American psychiatry. It’s gratifying to see that most
reviewers consider it vital that that moment be examined, and that we ask,
very seriously, whether all of the changes introduced in the 1980s were
necessary and precise. I don’t happen to think they were, and 99% of the
extensive feedback I’ve received, largely as email but also as a few
voicemails, has been from the general public agreeing with me.
When my piece about the book and the overemphasis on drug treatments
appeared in the New York Times and reprinted the same day in the
International Herald Tribune, I received dozens of emails from all
around the world—from France to New Zealand, Canada to Guatemala, indeed
from Italy too, and of course from all across the States. It was a little
overwhelming, but made me realize that the column and the book tapped what
I believe is widespread public concern about the overdiagnosis and
overmedication of especially young children. I’ve since heard from quite a
lot of doctors and psychiatrists, too, almost all of them voicing support
and relief. They’re genuinely grateful that someone is airing these
matters.
GP In your book
you say that when you examine the track record of drugs promoted as
efficient, speedy, and accurate, you quickly discover that they’re
anything but. What drug do you examine most closely in your book?
CL The drug that I examine
most closely in my book is Seroxat (“Paxil” in the States):
it can’t in fact discriminate
between routine stress and chronic anxiety, so it ends up blocking almost
all such signals from the brain and central nervous system, with worrying
health risks for patients.
When shyness is rebranded as “social phobia,” moreover, all psychological,
social, and even environmental factors causing reticence in people can
fall out of the picture. They’re replaced by questionable language about
“chemical imbalances” in the brain and “biological dysfunctions” leading
to “maladaptive” behaviors.
I find much of that emphasis troubling and questionable. For one thing,
it’s not an accurate way of talking about shyness or anxiety. Yet it seems
to settle complex matters by suggesting that biology and genetics are able
to pinpoint precisely what’s going on, and no-one else need trouble
themselves about such matters. Still, no-one can really say when the brain
is “chemically balanced,” because, for instance, its levels
of serotonin, dopamine, and norepinephrine fluctuate all the time. And
while many U.S. commentators love to speculate that there’s a gene or even
hormone for shyness, this is simply conjecture hardly worth the amount of
time and space devoted to it. It’s one thing to say that genes are
responsible for things like eye-color; it’s quite another, of course, to
assert that they cause widespread and entirely unremarkable
behavioral traits.
GP
DSM is widely considered the “bible” of psychiatrists, but you don’t seem
to think the manual is “highly scientific.” Why?
CL Well, the American
Psychiatric Association was generous in giving me unprecedented access to
its archives, so I was able to review all the letters, memos, documents,
and even votes that circulated behind the scenes, before the creation of
DSM-III. That was the crucial third edition that appeared in 1980
with 112 new disorders. Believe me, when you study such correspondence—I
reproduce a lot of it in the book—you quickly lose any impression that
what was going on was highly scientific or driven by careful clinical
research. The correspondence instead reveals extraordinary lapses in
professional judgment, embarrassing haste in cobbling together vague and
questionable lists of symptoms, turf battles and interpersonal rivalries
among the psychiatrists, a sometimes appalling poverty of group
intelligence, frequently tiny case studies, and a general sense that
anyone with friendly ties to the key task force members could get their
pet theory formalized as a major disorder. It isn’t a pretty picture,
which surely is a key reason this embarrassing chapter of American
psychiatry was buried behind a façade of rhetoric about hard science and
pristine research. But, as I show in the book, that façade isn’t accurate.
Quite the contrary, it hides a reality that people really need to know
about.
GP
Is there any difference, according to you, between “shyness” and “social
phobia”? Where should we draw the line between the two?
CL Yes, there are—or should
be—key differences between them. Shyness is a common personality trait
that’s perfectly normal. Roughly half of any given population (including
that of the U.S.) considers itself shy. Social phobia, by contrast, is
meant to refer only to those suffering from chronic amounts of anxiety
about interacting with other people. The problem is, the psychiatric
literature on the two repeatedly confuses them (as, indeed, does the
DSM), so ordinary shyness is now easily seen as a mental disorder.
Most psychiatrists that I interviewed told me, however, that the cut-off
point between shyness and social phobia is relatively clear: on the order
of 2% of seriously anxious patients they saw, as opposed to the
unbelievable figure of one in five Americans (almost 19% of the U.S.
population), which some psychiatrists have claimed is the correct figure.
GP
And what about the “social anxiety disorder”? Why, according to you, have
psychiatrists provided another definition so similar to that of “social
phobia,” which meets more or less the same criteria of it?
CL That’s a good question.
In 1987, when several psychiatrists were appointed to revise DSM-III,
they argued that “social anxiety disorder” was a better name for “social
phobia,” because it reflected more accurately behaviors that they were
seeing in the general population, including public speaking anxiety,
dating anxiety, and even anxiety about dealing with figures in authority.
To my mind, none of those common fears amounts to a mental disorder. On
the contrary, they’re so widespread as to be part of everyday psychology.
But the psychiatrists updating the manual didn’t see it that way. They
thought they were helping everyone by calling such behaviors symptoms of
social anxiety disorder. They also pressed for “social phobia” to be
renamed so that it would include a great many more of us. And they
succeeded. The list of official symptoms of social anxiety disorder grew
accordingly, and many more people (over 18.5 million North Americans and 3
million Britons) were prescribed Seroxat/Paxil as a result.
GP
In the New York Times you warned about overmedication and/or
medicalization of society: what did you mean exactly?
CL As the above example
hopefully shows, many people are taking medication they don’t really need.
Indeed, large numbers of psychiatrists prescribing drugs have I think come
to accept a blurred distinction between chronic anxiety and routine fears,
meaning they’ll offer medication in either case. We’ve even reached the
point in the U.S. and Britain where very young children—sometimes as young
as four and five—and being given psychiatric drugs, with the hope that
their childhood traits can be medicated away before they grow, apparently,
into adult disorders. To my mind, that’s a very troubling picture.
When Rebecca Riley, a 4-year-old girl from
Hull, Massachusetts, died
last year from psychiatric medication, there was an outcry from the public
demanding to know what on earth was going on. In Boston, Massachusetts
General Hospital admitted with some embarrassment that, in its care, 955
children under the age of 7 were taking the same antipsychotic medication.
In fact, that’s really just the tip of the iceberg, because it represents
just one U.S. hospital, but it hopefully gives your readers a sense of the
scale of the problem and the kind of thinking we’re up against.
In some quarters, the belief that drugs are necessary to stamp out
childhood traits amounts to a kind of fundamentalism. The psychiatrists
are so adamant that what they’re doing is correct and necessary that they
continue to say even-larger numbers of children and adults should be on
medication. I find that approach extremely worrying and arrogant. Almost
none of the experts will talk about the well-documented side effects of
medication—lists of symptoms so long they could fill several paragraphs.
Still, the mindset that assumes that drugs are always necessary and
the right course, no matter how small the problem, is what “medicalizes”
our society. We lose any ability to think about behaviors in other ways.
GP
If shyness is so common among human beings (in Philip Zimbardo’s research,
for instance, it is clear that the majority of people “are” or “were” or
“are on some occasions” shy), why do many people still consider it as a
“problem”? Why can’t people cope with it?
CL Especially in North
America today, people are encouraged to be highly extroverted and
outgoing. I’d say that it’s almost gotten to the point where the shy and
introspective are considered abnormal, even quite suspect, because they’re
perceived as “brooding,” “unresponsive,” even “antisocial.” Meanwhile, the
only type of personality the culture seems to admire is one that’s
“perky”: always “up” and “on” and ready to work articulately, with great
zeal, at the drop of a hat. Europeans are, in my experience, more
suspicious, even ironic, about such standards. Let’s be clear: It’s not
that gregariousness and enthusiasm are in themselves problems; both can be
very welcome and appealing. It’s more, as you say, that vast numbers of
people don’t fit that general picture and, indeed, mind that the culture
doesn’t view their thoughtful, even quiet, interactions with other people
as acceptable.
But it’s also more than that. If we’re ready to call dating anxiety and
public speaking aspects of a mental disorder, as the DSM encourages, then
we’re also creating a norm that’s not only undesirable for a great many of
us; it’s also quite unattainable. The model of American “perkiness” on
offer is more than unattractive, one-dimensional, and emotionally limited;
it’s also in some cases the cause of fresh suffering, because it
represents an ideal that most of us can’t hope to live up to.
Quite honestly, in today's world, with so much suffering on display and so
many justifiable grounds for concern, to be perky all the time could look
as if it was a fraction out of touch with reality. Certainly,
it’s difficult to maintain that outlook after one opens a newspaper or
watches the world news.
GP
Do you think there might be cases in which a drug is a relief for a shy
person, or at least a valid support to psychotherapy?
CL I’m
often asked this question, and it’s not easy to answer, because the
circumstances vary so much from one person to the next. In general, yes,
to the surprise perhaps of some of your readers, I am prepared to say that
drug treatments—combined with psychotherapy—may on occasion be useful,
even necessary, for people with truly chronic and impairing anxiety. I’m
not, then, a fundamentalist of another stripe: the kind that opposes
medication on all grounds, regardless of its advantages. Medication can in
general keep many people alive and protects us from harmful, sometimes
deadly, diseases and viruses; one can’t dismiss that fact because it
doesn’t fit our vision of humanity or society.
But psychiatric medication is a different matter, and while its
advantages in cases such as schizophrenia are relatively easy to quantify
(though still open to debate), its side effects are well-documented, its
long-term effects largely unknown, and its placebo effect very
substantial. The data submitted by the drug companies to the FDA about
such antidepressants was highly inconclusive. Placebo effect is
responsible for at least 80% of the drugs’ perceived advantages.
But we’re not at a point where we can rule out the possible benefits of
the remaining 20%. Until we can, it seems necessary to keep an open mind
about such medication while underscoring the risks of taking it and the
need to draw a firm diagnostic line between acute anxiety or depression
and routine fears and sadness. As Freud put it, there’s a clear
distinction between “hysterical misery” and “common unhappiness.”
GP
Having said that psychiatric research and DSM are practically handled by
Big Pharma, have you received any response, attack, intimidation?
CL Basically, no, and I
hope it stays that way! All that I’ve received are a couple of angry
emails from people who edit websites about social anxiety, but their main
complaint—that I’m ignoring or downplaying the plight of those with social
anxiety—is easy to rebut, because I am concerned about those with
chronic anxiety and would never trivialize what they’re experiencing. It’s
more that I disagree with the way social anxiety disorder was created and
pushed, including the list of routine symptoms that it’s come to include.
At points like that, it’s useful to recall, as I do in the book, that the
man responsible for recognizing social anxiety (Isaac Marks, now emeritus
professor of psychiatry at the University of London) strongly argued
against its being listed as a separate anxiety disorder. He added that it
was, in general, a perfectly normal reaction to the stress of interacting
with other people. In other words, we’re abnormal if we don’t
experience some amount of it. Those two factors, it seems to me, are
crucial to keep in mind.
GP
Did you imagine, while writing this book, that it would create such a fuss
all over the world?
CL I honestly couldn’t have
predicted how widespread the response would be. Certainly, I knew I was
dealing with provocative, even incendiary material that would upset many
of the leading figures. When you see in black-and-white what they were
arguing and how they were behaving, they really don’t come off looking
very good. But my guiding impulse throughout was that this material was
more a matter of public interest: We need to know a lot more about the
disorders that were pushed so aggressively in the 1990s as widespread
problems and the drugs that were pushed with equal zeal as their remedies.
Above all, then, I wanted people to know the back-story to the creation of
the new disorders so that they could judge for themselves whether the
conditions had been overblown or described with appropriate alarm. My book
doesn’t pull any punches on this: Based on all the evidence to hand (and
there’s lots I reproduce in the book), I think it’s clear the problems
have been exaggerated and hyped out of all proportion, with experts
declaring quite seriously that we’re now witnessing an “epidemic” of
shyness. But people need to make up their own minds about this, after
seeing all the facts presented and weighing both sides of the story.
GP
Are you going to publish your book in Italian?
CL
I
very much hope so. It’s coming out in French next year with Editions
Flammarion, and I gather that Yale Press is fielding interest from other
European publishers. Having published one essay with
Editore Feltrinelli, I’d be delighted if they or a
comparable press wanted to publish the book in Italian.
Giuliana Proietti
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