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Margaret Wente

Is your sanity at stake? Add to ...

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."

One of today's most inflammatory debates concerns post-traumatic stress disorder, a condition that afflicts soldiers who've served in combat zones. In the post-Vietnam War United States, the standard estimate of PTSD incidence among veterans is a whopping 31 per cent. (It's much lower in Canada, about 13 per cent or so.) The diagnosis is important because it opens the door to treatment and disability payments. But many of the symptoms - irritability, sleeplessness, aggression, poor concentration and so on - are quite general. Depression, anxiety and phobia can be misdiagnosed as PTSD.

A more fundamental problem is that the connection between current stress and past exposure to trauma can be uncertain or even non-existent. Memories are notoriously uncertain and, as time goes on, people tend to misremember past events, sometimes recalling them as worse than they really were. One study even found that the rate of PTSD among veterans has no correlation with their exposure to traumatic events.

"PTSD is a real thing, without a doubt," said Harvard expert Richard McNally in an article in Scientific American. "But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD and thus mistreating them."

He and other experts argue that "saving PTSD from itself" will require a shift in thinking, so that most post-combat distress will be regarded not as a disorder but as a part of normal, if painful, healing. It might be useful to apply that shift in thinking to other problems, such as, say, social anxiety disorder. After all, some of us are just born introverts. Human behaviour varies widely, and life is sometimes painful and difficult. The psychiatric establishment should try to get over it.

Unfortunately, there's no sign of that. One DSM chief admitted that delisting anything from the psychiatric bible is highly unlikely, because of the black eye it would inflict on the profession. Meantime, we can look forward to the possible inclusion in the next edition of compulsive shopping, compulsive sexual behaviour, and Internet addiction. If you're not in there now, you will be soon. As my grandma used to say, "The only sane people left in the world are thee and me - and I'm not so sure about thee."

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