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Last month, Britain's Daily Telegraph ran an important article on the near-certain expansion of diagnostic parameters for popular disorders such as social anxiety disorder.
The article reported that the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, which the American Psychiatric Association is expected to release in 2013, will almost certainly broaden "the diagnostic criteria for many supposed conditions including social anxiety disorder, better known as shyness, and will likely be adopted by the health authorities in Britain after appearing first in the US."
The concern and skepticism surrounding the move is significant, coming as it does from a major national newspaper. "The proposed new definition for social anxiety disorder," reports the Telegraph, "states that it is marked by ‘fear or anxiety about one or more social situations in which the person is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech).'"
In children, the newspaper adds, this fear could be expressed by "crying, tantrums, freezing, clinging, shrinking or refusal to speak in social situations."
"Clinging," "freezing," or "shrinking"? Is the APA serious? Alas, it appears so, and with troubling consequences.
According to the Telegraph, again reporting on developments in Britain, "recent figures show 650,000 children aged between eight and 13 are on the psychotropic drug Ritalin, up from just 9,000 two decades ago, while others are taking Prozac for depression or anxiety. Fears are growing that the number of children diagnosed with mental disorders and prescribed drugs will increase still further after 2013, when a new ‘bible' of the psychiatric profession is published."
To buttress the Telegraph's concern (though the article doesn't mention the following), it's worth adding that the fourth edition of the DSM carries a warning that psychiatrists should not confuse social anxiety disorder with shyness, doubtless out of concern about how overlapping the two have become. As Samuel Turner and his colleagues noted in 1990 in the journal Behaviour Research and Therapy, "Interestingly, the central elements of social phobia, that is discomfort and anxiety in social situations and the associated behavioral responses,... are also present in persons who are shy." Well-documented efforts to lower the disorder's diagnostic threshold, including by giving the disorder a new name (it was previously called "social phobia"), also led to a surge in diagnoses, to the point where the disorder was said to afflict almost one-in-five Americans (18.7%, according to one influential study published in the American Journal of Psychiatry in 1994).
But here's how that happens: If you include fear of "freezing" among children asked to perform or recite in public, the chances are strong you'll wind up with a fairly large number of diagnoses, especially if fear of public speaking is one of your guiding criteria. So the question quickly becomes, What number of children wouldn't be eligible for such a diagnosis? As we know that shyness and introversion rates in British and U.S. children consistently hover around the 50% mark, for boys as for girls, and that the same rates continue more or less unchanged into adulthood, is the APA saying it would support the medication by psychotropics of close to half of all American children and teens, as well as half of those in all other countries? Perhaps more pointedly, what are psychiatrists thinking in seeking to include such routine behavioral fears in a diagnostic manual of mental disorders with global influence?
"Young people," the Telegraph warns, "will be deemed as having oppositional defiant disorder if they display symptoms including losing their temper, arguing with adults, deliberately annoying people or being ‘spiteful or vindictive at least twice within the past six months' to people other than their brothers or sisters.'"
"‘Spiteful or vindictive at least twice within the past six months'"?: I don't know any children to whom that could possibly apply.
Not surprisingly, the newspaper adds, after citing strenuous concern about such diagnostic overreach from several prominent British experts, "the British Psychological Society has also raised concerns about the proposed revisions to the DSM."
The BPS "does not dispute that some children have emotional and behavioral problems," the article notes, "but says that patients and the public are ‘negatively affected' by the continued ‘medicalisation' of natural and normal responses to their experiences, and that classifying such problems as ‘illnesses' ignores their wider causes."
But rather than appropriately raising the diagnostic bar for such disorders and deleting some of the manual's more routine and absurd criteria, influential members of the DSM-5 task force are committed to seeking out "premorbid conditions" and to treating them with powerful psychotropic drugs, in an effort to "stamp out" the risk of such conditions surfacing later in life.
The Telegraph quotes Kate Fallon, general secretary of Britain's Association of Educational Psychologists, on the fallacy of such thinking, especially on presumptions of its diagnostic accuracy and clinical prediction:
"Behaviours develop over a long period of time, often with a range of complex causes. We can't ‘cure' the behaviours we don't like with a quick fix of medicine. They usually require careful management by all the adults around the child."
Even so, she adds, in 2013 "we're expecting new criteria for the definition of mental illness to be adopted here in the UK. These criteria will lead to many more children being diagnosed as mentally ill, based on reports of their behaviours." Indeed, as this blog reported back in the spring, the British government is investigating why Ritalin and other behavioral drugs have been prescribed in large numbers to children as young as four. We also have focused on how Social Anxiety Disorder was designated and expanded in the past.
"A shy child could be diagnosed with social anxiety," adds Fallon; "a sad or temporarily withdrawn child could be diagnosed with depression. These are conditions [that] are also likely to be treated with medication and under these circumstances, Congress, we will be putting potent drugs into children with little or no understanding of what it will lead to."
The Telegraph article appears here. For more information on how much shyness and social anxiety disorder overlap, visit christopherlane.org. You can also follow me on Twitter: @christophlane
