Are you afraid of going to parties full of strangers? Are you anxious at the thought of speaking to large groups? Does the customs officer at the airport make you nervous, even though you have nothing to declare? Do you dislike eating alone in restaurants?
Don't worry, you're not alone. These symptoms are typical of social anxiety disorder, an affliction that affects millions. You can look it up. It's in the book - the Diagnostic and Statistical Manual of Mental Disorders, which is the bible of psychiatry. Counselling and/or drugs can work, although I find a stiff drink helps, too.
For the past 60 years, the DSM has been used to catalogue what ails us in the head. There are more and more ailments all the time. The fourth edition, published in 1994, was 400 pages longer than the third. It lists hundreds of different types of mental illness, including such previously overlooked problems as intermittent explosive disorder, antisocial personality disorder, conduct disorder, and oppositional defiant disorder - all of which could be synonymous with “my kid is acting out and driving me crazy.”
The battle for control of the fifth edition, due out in 2012, is well under way. It will be the thickest volume yet. Some advocates are plumping for “apathy disorder,” a problem I confess to having whenever someone mentions the prospect of a fall election. We need to “get excited” about apathy, argues James Duffy, a psychiatry professor at the University of Connecticut Health Center, because it is alarmingly widespread and has high social costs. According to him, apathy often goes undetected because apathetic people don't care enough to complain about it.
Then there are the people at the opposite extreme - the ones seething for revenge. They're the kind of people who can't stop ranting about how George Bush ruined their retirement account, the real-estate market and the entire Western world. According to German psychiatrist Michael Linden, these people suffer from “post-traumatic embitterment disorder.” He, too, is lobbying for its inclusion in the DSM-V. “They figure the world has treated them unfairly,” he told the Los Angeles Times. “It's one step more complex than anger. They're angry plus helpless.” Yep, sounds like a former brother-in-law of mine.
The stakes are high in the battle for an official diagnostic label. Careers, research programs, marketing campaigns and pharmaceutical profits all depend on them. Health-care plans won't cover the costs of therapy or drugs without a diagnosis. But the symptoms of these illnesses tend to be broad, overlapping, imprecise and common. The distinctions between a mild case and a severe one are hard to draw. And the bar for diagnosis is sometimes very low.
After the drug Paxil was approved in 1999 for the treatment of social anxiety disorder, its makers launched a $92-million awareness campaign whose theme was “imagine being allergic to people.” A lot of people did. In 2001 alone, doctors wrote 25 million new prescriptions for Paxil, and sales soared 18 per cent.
“In my mother's generation, shy people were seen as introverted and perhaps a bit awkward, but never mentally ill,” says Christopher Lane, author of the book Shyness: How Normal Behavior Became a Sickness. “This and other advertising campaigns helped change the way Americans think about anxiety and its treatment.”
Untreated mental illness is a devastating social problem. But pathologizing normal behaviour is probably not the answer. In fact, it may make the problem worse, by drawing resources and attention away from truly serious conditions such as major depression.
Even the experts who oversee the DSM worry about what's known as diagnostic bracket creep. As one of them, David Kupfer, said in an interview: “One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis.”
