In Oren Rudavsky’s recent film, The Treatment, a wealthy Manhattan widow is baffled that a schoolteacher might be so anxious about speaking in public that he can’t eat and suffers from stomach cramps and diarrhea. After all, surely he must speak in front of others every day. His reply is, in effect — well, yes, but only in front of students. The schoolteacher probably wouldn’t take any comfort from the popularity of his fear: According to one notorious statistic, Americans are more afraid of public speaking than of death.
I’ve begun with this example it points up a real enigma about our minds: How can a purely cultural experience such as public speaking translate into brain chemistry? After all, neither term in “public speaking” is straightforward. How big a group counts as “public”? Are they friends, colleagues, strangers, or a mix? Am I drunk or sober? Am I reading a prepared speech? fielding questions? participating in a judicial, civic, or religious ritual? How is it that our serotonin levels are able to make such finegrained judgments? Even if one focuses just on physical responses — mild sweat, an elevated heart rate — people may well attribute different meanings to those responses. (I was scared / I was in the zone / I was angry.) Despite these difficulties, some psychiatrists have proposed that “public speaking phobia” ought to receive its own diagnostic classification.
By focusing on the intersection between culture and chemistry, Christopher Lane’s wonderful new book, Shyness: How Normal Behavior Became a Sickness (Yale UP, 2007) shows why we ought to be more skeptical of the rush to medicate “social phobias” — Psychology Today‘s “disorder of the decade”! — with powerful drugs, especially in children and adolescents. Despite the alleged precision of recent editions of the Diagnostic and Statistical Manual of Mental Disorders, “social phobia, the most enigmatic and poorly-defined anxiety disorder, became the psychosocial problem of our age.” It is as if the very vagueness of the definition allows its meaning to expand, until 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.” What’s worse, he suggests, the drugs we expect to fix our problems all too frequently fail to do so, and in many cases actually make matters worse.
…The second part of the book focuses on the tight fit between the turn to neuropsychiatric models of diagnosis and the marketing demands of big pharma. The side effects of these powerful drugs make a mockery of the word “selective” in selective serotonin-reuptake inhibitor (SSRI). As we are beginning to understand more fully, SSRIs are a decidedly mixed blessing, and their consumer-orientated marketing is unseemly at best. …
Let’s begin with your most serious claims. You argue that social anxiety disorder is conceptually overbroad and overdiagnosed, while Paxil and the other drugs prescribed for this disorder are ineffective, if not outright dangerous, for many patients. But you also argue that the role of serotonin in mental illness is vastly overstated, and in fact has no direct causal relation. At the risk of sounding naïve, how did the mythology around serotonin take hold?
I think a lot of the mythology about low serotonin sprang up when neuropsychiatrists in the 1970s and ’80s championed biological explanations for mental illness. Their goal was really to help us think that such distress stemmed from the brain rather than the mind. In June 1976, for example, Robert Spitzer, then chair of the task force overseeing major revisions to DSM-III (the third edition of the Diagnostic and Statistical Manual of Mental Disorders), tried to get approved a very bold claim: “A mental (psychiatric) disorder is a medical disorder.” He wasn’t successful, because so many pointed out the enormous influence of psychological and social factors in shaping mental distress. But Spitzer’s argument has since gained momentum because it’s appealingly straightforward and has so much financial support. If we can say that the cause of distress is a “chemical imbalance,” then the solution points logically to drug treatments rather than therapists focusing on the mind by, say, encouraging a shift in perception.
But just one of many problems with the “chemical imbalance” argument is that it oversimplifies so much. No one can establish conclusively what a chemical balance is because it varies so much from one person to the next and, indeed, from one day to the next.