Shy on Drugs
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By
Published: September 21, 2007
FEW
children relish the start of a new school year. Most yearn for summer to
continue and greet the onset of classes with groans or even dread. But among
those who take the longest to adapt and thrive, psychiatrists say, are children
trapped in a pathological condition. They are so acutely shy that they are said
to suffer “social anxiety disorder” — an affliction of children and adolescents
that, the clinicians argue, is spreading.
It
may seem baffling, even bizarre, that ordinary shyness could assume the
dimension of a mental disease. But if a youngster is reserved, the odds are
high that a psychiatrist will diagnose social anxiety disorder and recommend
treatment.
How
much credence should we give the diagnosis? Shyness is so common
among American children that 42 percent exhibit it. And, according to one major
study, the trait increases with age. By the time they reach college, up to 51
percent of men and 43 percent of women describe themselves as shy or
introverted. Among graduate students, half of men and 48 percent of women do.
Psychiatrists say that at least one in eight of these people needs
medical attention.
But
do they? Many parents recognize that shyness varies greatly by situation, and
research suggests it can be a benign condition. Just two weeks ago, a study
sponsored by
On
what, then, do psychiatrists base their sweeping judgments? Most
point to The Diagnostic and Statistical Manual of Mental Disorders — the
fundamental handbook of psychiatry. Yet a glance at the manual reveals
that the diagnostic criteria for shyness are far from clear. The third edition,
which was published in 1980, said that a person could receive a diagnosis of
what was then called “social phobia” if he was afraid of eating alone in
restaurants, avoided public restrooms or was concerned about hand-trembling
when writing checks.
The
same guidelines could hardly apply to youngsters heading to kindergarten,
children not yet potty-trained and toddlers just learning to eat. So in 1987,
the revised third edition of the manual expanded the list of symptoms by adding
anticipated concern about saying the wrong thing, a trait known to just about
everyone on the planet. The diagnostic bar was set so low that even a
preschooler could trip over it.
Self-help
books and magazine articles further widened the definition of social anxiety
disorder to include symptoms like test anxiety, aversion to writing on the
blackboard and shunning of team sports. These ridiculously loose criteria led
to more diagnoses, until social anxiety disorder in children began to look as
if it were spreading like the common cold among second graders.
Then,
having alerted the masses to their worrisome avoidance of public restrooms, the
psychiatrists needed a remedy. Right on cue, GlaxoSmithKline, the maker of
Paxil, declared in the late 1990s that its antidepressant could also treat
social anxiety and, presumably, self-consciousness in restaurants. Nudged along
by a public-awareness campaign (“Imagine Being Allergic to People”) that cost
the drug maker more than $92 million in one year alone ($3 million more than
Pfizer spent that year promoting Viagra), social anxiety quickly became the
third most diagnosed mental illness in the nation, behind only depression and
alcoholism. Studies put the total number of children affected at 15 percent —
higher than the one in eight who psychiatrists had suggested were shy enough to
need medical help.
This
diagnosis was frequently irresponsible, and it also had human costs. After
being prescribed Paxil or Zoloft for their shyness and public-speaking anxiety,
a disturbingly large number of children, studies found, began to contemplate
suicide and to suffer a host of other chronic side effects. This class of
antidepressants, known as S.S.R.I.’s, had never been tested on children.
Belatedly, the Food and Drug Administration agreed to require a “black box”
warning on the drug label, cautioning doctors and parents that the drugs may be
linked to suicide risk in young people.
You
might think the specter of children on suicide watch from taking remedies for
shyness would end any impulse to overprescribe them. Yet the tendency to use
potent drugs to treat run-of-the-mill behaviors persists, and several
psychiatrists have already started to challenge the F.D.A. warning on the
dubious argument that fewer prescriptions are the reason we’re seeing a spike
in suicides among teenagers.
The
recent book “Nurturing the Shy Child: Practical Help for Raising Confident and
Socially Skilled Kids and Teens,” insists, “Don’t be afraid to try medication.”
“When an S.S.R.I. is properly prescribed and monitored, medication can be very
helpful,” say the authors, two psychologists. This book says it is a sign of
social anxiety disorder if a child complains about or tries to avoid asking the
teacher a question or getting up from his or her desk to sharpen a pencil.
Clearly,
there is a need to reconsider the diagnostic standards. A team of mental health
experts has recently gathered to oversee a new edition of The Diagnostic and
Statistical Manual, and this time they should make sure to carefully
distinguish normal — even healthy — shyness from social anxiety disorder. They
should also remove shyness from the lists of symptoms of avoidant personality
disorder and schizoid personality disorder. With so much else to worry about,
psychiatry would be wise to give up its fixation on a childhood trait as
ordinary as shyness.
Christopher
Lane, a professor of English at Northwestern, is the author of the forthcoming
“Shyness: How