Shyness: How Normal Behavior Became a Sickness

by Christopher Lane

In the 1970s, a small group of leading psychiatrists met behind closed doors and literally rewrote the book on their profession. Revising and greatly expanding the Diagnostic and Statistical Manual of Mental Disorders (DSM for short), they turned what had been a thin, spiral-bound handbook into a hefty tome. Almost overnight the number of diagnoses exploded. The result was a windfall for the pharmaceutical industry and a massive conflict of interest for psychiatry at large. This spellbinding book is the first behind-the-scenes account of what really happened and why.

 

With unprecedented access to the American Psychiatric Association archives and previously classified memos from drug company executives, Christopher Lane unearths the disturbing truth: with little scientific justification and sometimes hilariously improbable rationales, hundreds of conditions—among them shyness—are now defined as psychiatric disorders and considered treatable with drugs. Lane shows how long-standing disagreements within the profession set the stage for these changes, and he assesses who has gained and what’s been lost in the process of medicalizing emotions. With dry wit, he demolishes the façade of objective research behind which the revolution in psychiatry has hidden. He finds a profession riddled with backbiting and jockeying, and even more troubling, a profession increasingly beholden to its corporate sponsors.

 

 

Genres: Nonfiction, Psychology, Mental Health, Psychiatry, Science, Sociology, Mental Illness

272 pages, Paperback

First published May 1, 2005

About the author

Christopher Lane is a regular contributor to Psychology Today who for many years taught medical humanities, Victorian studies, and the history of medicine at Northwestern University.

He is the author of six books, most recently Surge of Piety: Norman Vincent Peale and the Remaking of American Religious Life (Yale, 2016), on Peale’s self-described “religio-psychiatric” clinic and movement in the 1950s.

His other books include The Age of Doubt: Tracing the Roots of Our Religious Uncertainty (Yale, 2011) and the award-winning Shyness: How Normal Behavior Became a Sickness (Yale, 2007) on behind-the-scenes changes to the DSM and the creation of the anxiety disorders between the 1970s and 1990s.

Lane’s work has appeared in the New York Times, Washington Post, Boston Globe, Los Angeles Times, Slate, TIME, Chronicle Review, Huffington Post, Daily Beast, and several other newspapers and magazines.

Reviews

[Georgia Scott · Rating 4 out of 5]

Introductions are a bore. Not this one. It begins: " When my mother was six years old, she often pretended she was a horse. . . " I had two friends who "were" horses. One stopped when she got a boyfriend. The other did, too, last I heard. No one recommended medication for their "quirky behavior" any more than for that six year old.

"My grandparents shrugged off her equestrian impressions as the charming impressions of a girl blessed with a vivid imagination, and waited patiently for her to change." She did, as far as trotting around, and put her imagination into a successful musical career. I changed, too. No more rubber spiders in my purse. Imagination now pushes me to reach for a pen.

As for being shy, I am still that. You wouldn't know. There are more of us than people guess.

[e.h.d · Rating 1 out of 5]

I am mystified by the average rating, because this book, to be blunt, was awful. By around page 30 I could not take him seriously anymore. Any sort of credibility he could have had was conversely stripped by his poorly hidden disdain and I-know-everything tone. His obvious scorn towards the field of modern day psychiatry has him painting all psychiatrists as narrow-minded and even uncaring towards patients' situations.

This topic isn't anything new. There's been lots of discussion about where the line between 'personality' and 'disorder' should be drawn. That is why it was quite disappointing to realize that a book published in such recent years, 2007, by Yale no less (and apparently has even won an award?! wtf) has such a simple and blatantly biased view. This book TOTALLY and COMPLETELY undermines the suffering of those who truly /do/ have legitimate and debilitating mental disorders that make their daily lives a painful and exhausting and seemingly hopeless battle.

The introduction makes this clear enough: "My behind-the-scenes perspective confirms that deep-seated conflicts of interest, buried research data, professional ambition, and fierce marketing campaigns together have greatly exaggerated social phobia and avoidant personality disorder, turning behavior we recently accepted, and even welcomed, into pathologies needing medical treatment."

First of all, there are a handful of assumptions Lane makes here. Since when has social phobia (by Lane's terms, merely "shyness") and anxiety (simply "excessive worry", a natural and healthy reaction to stressful events) been "socially accepted"? Being quiet and withdrawn has never been quite what I would call a social ideal. Yes, introverts have their own charms, but the truth is that life is harder the less social skills you have. The worse it is, the more it affects your success in your career, relationships, health.

Second of all, even if the "we" that Lane speaks of accepts and welcomes these traits with open arms, what of the individual who is suffering? Lane is pretty much saying, "Well it's fine as long as WE don't have to suffer the consequences, deal with it on your own." Ummmm. Okay.

Here's another great quote: "The unavoidable conclusion is that we've narrowed healthy behavior so dramatically that our quirks and eccentricities- the normal emotional range of adolescence and adulthood- have become problems we fear and expect drugs to fix."

Okay. Here's an example of one of many sweeping overgeneralizations that litter this book. There is nothing "healthy" about having a severe social anxiety that keeps you from being able to hold a job, keep relationships, and in general fend for oneself. The author constantly and completely undermines that these kinds of problems are real, and consequently leaves the audience with the impression that people with this problem are just whining.

Lane also goes on to give an example of an old man who is suddenly gripped with anxiety and guilt for masturbating in his youth - this was in older times of stricter religious guidelines just for context- and is then diagnosed with depression and anxiety.

The example is totally ridiculous and again, depicting depression as silly, something we shouldn't take seriously, because really, some old dude who feels bad about jacking off just needs to get over himself. And Lane leaves us with that as our insight into the plights of people struggling with depression.

To be honest, I stopped seriously reading about halfway and just skimmed the rest, because it seemed to be one long complaint against Robert Spitzer and how Freud isn't worshipped enough.

This review turned out way longer than I planned but there were so many points that came across to me as offensive. He has no knowledge of the other side, took no time to try and understand the people with actual mental illnesses. As a professor he should have understood how this would have implications on how people viewed psychiatry, and consequently, psychiatric patients.

There is a way to inform people that psychiatry needs some serious reform without stigmatizing those people that NEED medication as simply 'unique and eccentric' or 'oversensitive and whiny.'

[Skylar Burris · Rating 2 out of 5]

I was interested in reading this book for a variety of reasons. One is that, as an introverted person who was at one time also shy, I have always felt that extroverts do not understand and often misjudge shy people and that, because they are outgoing, extroverts tend to set the expectations for "normal" behavior in society. A second reason is that, as I see increasing advertising for mood-altering drugs and hear of an increasing array of new disorders, I have become concerned that the line between personality and disorder is becoming blurred and that our present society, while giving lip service to the value of diversity with regard to race and religion, is perhaps seeking among its inhabitants a conformity of personality.

Full review here.

[Sandee · Rating 1 out of 5]

This book was awful, which is ashame because I actually agree with his position. However, not only was it terribly dry, but he makes these sweeping generalizations that are often inaccurate. He also jumps to conclusions and downplays multiple psychological issues that are typically more serious than he makes them out to be. Just one example of something that annoyed me was his position that the DSM has stopped using the word "reaction" for multiple disorders to make things seem more chronic and long-lasting. However, the DSM currently uses the word "episode" yet he makes no mention of that. Then I felt very annoyed that after building an entire case against the pharmaceutical company, he writes an entire chapter summarizing fictional stories as evidence of a backlash instead of real-life accounts. I didn't need to read 5 whole pages summarizing the movie Garden state in detail or another five breaking down the entire plot of Franzen's The Corrections. This should have been a good book and it wasn't.

[Kathleen · Rating 3 out of 5]

Hmmm..what to say about this book? I think it is an important book, with a well-researched and vital message about the overmedication of America and the involvement of the pharmaceutical industry in "selling" psychological problems. I just wish it hadn't been so dry in the first half, then wandering in the second half.

It raises the great question: How did shyness develop into a "diagnosis" -social anxiety disorder- that, if untreated by the latest pharmaceuticals, meant the person was not living life to the fullest? Who decided that everyone needed to be perky, extraverted, and gregarious all the time? What ever happened to the acceptance of personalities that embrace introspection, observation, and reserved behavior? And be warned: shyness is just the first normal behavior that has been so stigmatized. Expect that in the near future behaviors like internet addiction, compulsive buying, road rage, apathy, and the like to become named diagnoses subject to pharmaceutical marketing campaigns calling for patients to be medicated for their "problems".

One statement gave me particular pause:

"The drugs used to treat a mental disorder...may induce long-lasting biochemical and even structural changes [to the brain], which in the past were claimed to the cause of the disorder, but may actually be an effect of the treatment."

Readers, please heed this author's warning and think twice about taking mood-altering medication without fully understanding the above statement. Drugs like Paxil, Prozac, Zoloft, and the like may alter the functioning of your brain - perhaps permanently. Think seriously about other therapy alternatives before you medicate yourself so you can be more at ease speaking in front of groups, or eating in public. Perhaps you're not sick, you're just shy. After all, this could be your brain on drugs.

[Abby · Rating 4 out of 5]

As an introvert myself, I was intrigued by the title. Someone thinks I'm not abnormal.

In fact, this book goes to great lengths to show that introverts were labeled mentally ill, not because of a need for treatment but because American society values out-going personalities and psychiatrists wanted job security - but mostly because psychiatrists wanted something to cure. Psychiatrists think psychologists are Freudian, and Freud is wrong. It's not emotions and history that make people be what they are or act the way they do; it's brain chemistry, and chemical imbalances are fixed with drugs.

Well, not quite. Christopher Lane explains in minute detail how Robert Spitzer, chair of the committee to rewrite the DSM (specifically edition III) used manipulation, intimidation, and selective listening to create a group to rewrite the DSM they way he wanted it. Basically, he wanted more things to diagnosis and treat by changing definitions to lower the requirements for a mental disorder - and drug companies lapped it up. Problem is, psychologists are not quacks and drugs aren't nearly the cure-all psychiatrists want them to be. Not only are they not much more effective than placebos, the side effects and withdrawal symptoms are much worse than those disclaimers in tv ads lead you to believe.

If you wade through the second and third chapters, the book gets easier to read. There isn't as much shop talk and Lane's near fanatical hatred of Spitzer isn't the topic of the later chapters. Instead, Lane explains how drug companies have withheld or whitewashed information to keep their drugs attractive to people who didn't know they were sick until they saw the tv or magazine ad. Granted, chapter six, exploring the backlash against drugs as seen in books and movies, seems a bit out of place; almost like a separate paper written in college and inserted in the book. However, the story Lane describes about a pharmaceutical group commissioning a book makes one wonder if Karl Rove sidelined for pharmaceuticals.

What I find odd is, if psychiatrists don't like emotions or past experiences as reasons for problems (I'm not going to call them mental disorders), why do they use them to diagnose problems. If they think it's all brain chemistry, shouldn't they be running scans or pathology tests?

[Katherine · Rating 2 out of 5]

I am of two minds on this book. On the one hand, the author makes some excellent points. He reproduces some of the communications between the authors of the DSM-III during its writing. The contempt that some of the authors displayed towards their patients and the insistence that certain behaviors or beliefs they disapprove of must be symptoms of mental illness is breathtaking, as is the acrimony between the authors. The actual process of writing the DSM-III was not particularly scientific and cutoffs were set arbitrarily, but Lane doesn't mention that this has also been true of other fields of medicine: this is true of the cutoffs for diabetes and high blood pressure as well. He hints that the broadening of disease categories and the the categories' inability to distinguish between mild and severe illness were driven not by science, but by the desire to ensure that insurance would cover treatment, as well as the conviction that if someone is experiencing mental suffering, that must be a result of mental illness (by this argument, presumably the entire country of North Korea is mentally ill). He also highlights the lack of plausibility for some of the claims about social anxiety disorder (SAD): it is frequently claimed that SAD is highly prevalent and debilitating. Unless clinicians are using a different definition of debilitating, either SAD is highly prevalent, or the typical patient is debilitated. There are simply too many people holding down jobs, forming families and generally living normal lives for a large part of the population to be suffering from debilitating SAD.

He also makes some good points on SSRIs. For more than thirty years, scientists have been trying to prove the "chemical imbalance" in the brain hypothesis of mental illness and have been been unsuccessful. Few scientists today endorse the chemical imbalance hypothesis, and yet, the author points out, the public clings to it to the point that if you point out the hypothesis has very little evidence to back it up you can be expected to be accused of ignorance and being one of those people who causes the stigma of mental illness.

Any objective scientific observer would conclude that the vast majority of people taking SSRIs should never have started taking them either because they're taking them for life situations or they are taking them for a mental illness that is not severe enough to respond to drugs. The author repeatedly states that SSRIs are no more effective than placebos. While this is true for most forms of anxiety disorders and depression, there are several exceptions: SSRIs are slightly more effective than placebos in very severe depression and panic disorder, though most of the effect is a result of the placebo effect. However, for melancholic depression (a very severe subtype of depression) and OCD, these drugs do have substantial benefits over placebo: a significant number of people with these diseases improve on the drugs, and the placebo response is very low in these diseases.

Lane's argument is that normal personality traits that society views less favorably have been transformed into a disease by committee. And pharmaceutical companies falsely claim it can be fixed with a pill. This is a legitimate argument, as there is plenty of evidence to support it, but the author repeatedly undermines his argument by exaggerating or overstating the evidence. I do think that SAD exists, but it's not the same thing is being shy, introverted, being a bit nervous at parties, or being afraid of public speaking. There is a book in parsing the difference between SAD and shyness/introversion etc, but this is not that book

[Amy Mann · Rating 5 out of 5]

I found Shyness to be a powerful book and an engaging read. It is very well documented and draws on a fascinating archive of unpublished papers at the American Psychiatric Association that shows clearly how the DSM was updated in the 1970s, with decisions that seem questionable to say the least. The Author details major debates about social anxiety disorder and its cross-over with shyness, including from interviews with many of the psychiatrists involved. This brings the material to life and keeps it from being dry, while highlighting controversies about diagnosis that clearly have not gone away. There's a chapter also on major side effects from popular meds that were withheld from general public, in ways that later caused a scandal in the press. Everyone taking those drugs should know about that history, to understand what was kept from them. I recommend the book highly for those working in healthcare, nursing, mental health, and psychiatry, but also the general public, who are likely to be surprised by what went on behind the scenes.

[Jennifer W]

So far (and I'm 15 pages into it), I'm not impressed. Twice now I have stopped and found an error in the text. The 1st being that 50% of Americans have mental illnesses, if you read *his* citation in the back of the book it actually says that 50% of Americans may develop a mental illness during their lifetime, the 2nd being that people who take SSRIs-Prozac, Zoloft etc- have low levels of serotonin, this is not true either. SSRI stands for Selective Serotonin Reuptake Inhibitor- they may have low levels, or they may have problems absorbing it (the drugs do not add serotonin; they prevent nerves from reabsorbing it), similar to people with type 2 diabetes- they may not have enough insulin, or their bodies may not be able to use what's available. Perhaps his next book will be about how Type 2 Diabetes was made up by pharmaceutical companies, I can't wait.

[The Angry Lawn Gnome · Rating 4 out of 5]

If this book does nothing else, it at least makes you think. Doubtless the author has his biases, particularly leaning toward Freud, but the story of how DSM-II became DSM-III (and IV and soon V) makes for appalling reading. It is not that the triumph of the "neo-Kraepelins," essentially the school of thought that all mental illness has some sort of physical cause, would particularly bother me (though it certainly does the author), it is the "palace coup" method of how their ideas came to the fore, and essentially have a stranglehold on psychiatry and psychology these days. Had it come about in a different fashion, via empirical methodology, I'd have no real problems with their model. But it has not, at least per Lane, and he quotes enough sources to make the claim a credible one.

Misc, grab-bag thoughts:

͏ The Drug Company/Research Lab connection Lane posits has no real "smoking gun," but I'm now inclined to accept that something along those lines exist. They got the $$$, the researchers want to research.

͏ It will be interesting to see if DSM-V addresses Lane's point of diagnosis overlap, either by tightening the definitions of conditions or dropping some entirely. I do know that the Asperger's Community is up in arms over the elimination of this term, and its repackaging as some sort of Autism Spectrum condition...I guess being diagnosed as an Aspie I should weigh in with some sort of opinion here, but I'm honestly not so sure the change doesn't make sense. It may not, but it just may.

͏ I'm going to have to dig into withdrawal problems, since I'm on all kinds of crap, for all kinds of conditions.

͏ The copies of the ads, particularly the ones from the '70s and earlier, were both funny and scary. At least in retrospect. I guess funny can't really apply during the time period they ran.

͏ Lane doesn't really seem to offer much in the way of a solution to this whole business. Doesn't detract from the rest of the work, but he certainly has no problem with being judgmental page by page. Surprised it is missing.

[Vanessa · Rating 3 out of 5]

This is an interesting and comprehensive overview on how shyness and anxiety - two natural states of mind - were turned into "disorders" by a group of psychiatrists brainstorming ideas to stick in the new Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in the 1970s, pressures from society at large to conform to the expectation that everyone be an extrovert, and especially big pharmaceutical companies trying to create a market for their products. The conclusion is that the world, and America in particular, is overmedicated. Particularly worrisome is the last chapter, describing some of the "disorders" worthy of medication that may be included in the next edition of the DSM (V), including apathy, road rage, compulsive spending and internet addiction. How about equipping people with the skills to deal with some worry, sadness, or dissatisfaction in their lives rather than dosing them up with drugs - all of which have some pretty serious side effects? As the New Yorker cartoon near the end of the book so eloquently states: "Can you up the dosage? I still have feelings."

[Susan · Rating 5 out of 5]

This book tells how the manual currently used to diagnose and label "mental illness" (such as shyness) came to be agreed on and codified--how the labels and what was included was largely an issue of ego, in-fighting, etc. while little to no thought was given to truthful common sense understanding of people, or to what effect labeling people might have on their lives. It's eye-opening and very important given the intrusion of the pharmaceutical industry on our general acceptanceof what kinds of expenditures, widespread levels of druggedness, and also addiction are considered desirable/advisable in society. And this material is of course ultimately potentially germaine to political control of citizenry.

[Yasmin · Rating 5 out of 5]

"Without romanticizing the figure of the tormented genius, [Lane] reminds us of the costs of being mired in an excess of equilibrium. In the end, he seems hopeful about the tide shifting against the overdiagnosis of social anxiety disorder and towards a resurgence of psychoanalysis. For the sake of our lives, we can only hope that he’s right."
Read the rest of my review here:
http://www.yasminnair.net/content/chr...

[Megan · Rating 3 out of 5]

Interesting info about the push to add anxiety-related disorders to the DSM in the 1980s, but it felt a little biased, drawn out and too heavy on statistics. I think if he had included more real life examples of people struggling to be diagnosed correctly or living with anxiety (and not so many from movies?) it would have helped. Again, I will mention the fact that a lot of nonfiction books really need some help with outlining and organizing so the book flows better (why do authors use so many page breaks?!).

[Cadmium Candy · Rating 3 out of 5]

An interesting concept, but i'm having a bit of trouble finishing it, it tends to ramble on a fair bit and include quotes which are far too long. It has a very artsy style which might make it readable for laity or people with a social sciences background, but gets a bit frustrating for a scientist to read.

[Kyla · Rating 2 out of 5]

"Read" should read "skimmed". More academic than I thought, I missed most of the early chapters on analysis and focussed on the DTC ads for Paxil etc. section. Still kinda dull! I like my academics anecdotal, yo.

[Kirstin · Rating 2 out of 5]

I started this years ago and i still haven't managed to finish it. Nice topic, but could be covered better in something a bit shorter. Who was it who said something about so many good essays being turned into bad books?

[June · Rating 4 out of 5]

If everyone read this book, noone would take antidepressants. Read this book. Don't take antidepressants.

[Dr Deborah · Rating 5 out of 5]

A Splendid Achievement

This is a vigorously researched, carefully argued book that will appeal both to clinicians and to a general audience.

As a psychotherapist in practice for 20 years, and as someone who supervises 4th-year psychiatry residents, I welcome the book as the latest addition to a growing arsenal in the fight against overmedicating America.

Christopher Lane tells the story of how social phobia--a serious psychological problem--came to be publicly understood, under the new rubric of "social anxiety disorder" as something that might afflict almost everyone. I see this in my practice all the time. Many new patients enter treatment mentioning that they saw the television ads that ask: Do you feel awkward at social gatherings? Fear speaking up at work? You may have Social Anxiety Disorder. Ask your Dr. about.... In great numbers they ask, and in great numbers are prescribed Paxil or another SSRI. At one point, there were 5000 Americans beginning a fresh course of Paxil every day.

The author observes wryly: "Before you sell a drug, you have to sell the disease" and he proceeds to tell a chilling tale about GSK.

[Manuel Heras · Rating 5 out of 5]

Muy necesario. He leído que a mucha gente le ha parecido aburrido y que consideran que la primera mitad sobra, cuando es, de lejos, la más relevante. Supongo que el problema es que el libro se vendiera como un libro para todos los públicos (y en parte esto está bien), cuando su público más mayoritario deberían ser los profesionales de salud mental. En definitiva, un libro imprescindible.

[Eduardo Lira · Rating 1 out of 5]

Circoanalista queriendo hacerla de periodista, termina mal, aburrido y desinformado.

[Carol D · Rating 5 out of 5]

Outstanding. Loved it.

[J. L. · Rating 5 out of 5]

I found this book a real eye-opener and also kind of fascinating and disturbing. It tells the story of how a team of psychiatrists put together the diagnostic manual that is now, amazingly, considered an authority the world over (used daily in schools, courts, and prisons, for medical insurance, assessment, etc), even though many of the entries and related discussions were frankly laughable and difficult to take seriously. The author builds a solid case over this confusion. The result of such poor definition and clarity in such an important manual (the DSM)? A major problem today with overdiagnosis and overmedication, with psychiatric disorders being too easy to give, because too many people reach the sometimes absurdly low bar for them -- e.g. shy people being too easily confused with those with social phobia, and thus eligible for medication like an antidepressant or worse. The author somehow gained access to all the unpublished papers, letters, and documents that went into the creation of the diagnostic manual, apparently detailing them for the first time, and then interviewed many of the psychiatrists responsible. Most of the book was a fairly easy read; parts of it were more technical, but I think that's to deal with psychiatric categories and arguments (themselves quite technical), to help convey why distinctions between shyness and social phobia are far less stable and clear than some of the psychiatrists responsible claim. It's a polemical book, but tied to evidence, with lots of documentation to prove the point, and I found it overall very compelling and definitely worth the read.

[Sally · Rating 3 out of 5]

The author holds that many normal behaviors, such as shyness, have been pathologized by the neuropsychiatric community and pharmaceutical industry, thus harming many members of the public. The book details how the process of forming "new" diagnostic catagories was often unscientific and full of personal and professional bias, by examining the correspondence and interviewing many of those involved; and also examins the role of pharmaceutical companies in promoting diagnoses for which they have medications and advertising the medications for widest sale as well as downplaying the medications side effects and overstating its benefits.

[Miranda · Rating 2 out of 5]

Pros: The concept of this book and the portrayal of the medicalization of everyday emotions is spectacular. It was eye-opening to see just how much sway the pharmaceutical company has in pushing sickness onto perfectly healthy people.

Cons: This book, for the most part, was incredible boring and took me a long time to get through. I was barely able to finish the last couple chapters of the book because it seemed to drag on for longer than necessary. Not only that, but Lane's writing style was long-winded and convoluted masking the main points of each chapter from the reader.

All in all the book is great at face value, but failed to deliver once you delve deep enough into it.

[Jen Robinson · Rating 2 out of 5]

I just couldn't get far into this book - the premise was fascinating (psychiatrists! drug companies! intrigue!) but the language was too dry and the constant footnote and statistic slinging rendered it less accessible than I would have liked. The author also seems to contradict himself a few times in the Introduction (about as far as I made it, although I did read a few pages into each of the chapters). This would have made a great NYT Magazine article, but as a book it lost my interest too quickly.

[Matthew · Rating 3 out of 5]

disturbing expose on how small-minded people made a normal condition into an "illness". worse on how the drug companies manipulated everyone after-the-fact. but this is dry prose that tells a story we should all already know.

[Kristin]

On faculty at Northwestern

[jen8998 · Rating 3 out of 5]

Nothing new here really. It's basically a critique of the process by which the DSM was formed. The author mainly focuses on the DSM-3 and rarely references the subsequent editions.

[Kris · Rating 4 out of 5]

A bit polemical, but lucid, revealing. Disturbing.