APA Gains Sanity: Introverts Not Nuts

Last summer, I teamed up with Laurie Helgoe, Ph.D., clinical psychologist and author of Introvert Power, to write "A Giant Step Backward for Introverts," about the proposed inclusion of introversion in the American Psychiatric Association’s forthcoming Diagnostic and Statistical Manual (DSM-5). The controversial inclusion of introversion in the DSM-5 would designate introversion as a contributing factor in diagnosing certain personality disorders.

Since we wrote that story, there’s been near-silence on the airwaves about news on this topic. Yet, in the latest iteration of the proposal to update the DSM-5, introversion has been quietly removed. Helgoe is back to chat about this.

NA: What are your thoughts about the absence of introversion from the DSM-5?

LH: First, I'm thrilled that it was removed. I'd like to throw—well, not a party—but some virtual confetti anyway. The inclusion of introversion in the DSM was a huge concern, and the APA could have relieved a lot of stress and anxiety (which is what they're about, isn't it?) by letting interested parties know that the term would not, in fact, be used as an indicator of psychopathology. I think they lost the opportunity to educate, to restore the term "introversion" to its place as a descriptor of normal personality.

NA:

Over the past year, our readers vociferously objected to the inclusion of introversion in the DSM. Anonymous wrote: "The only time I feel my introversion is a problem is when I read stuff like this...." Beth Buelow, The Introvert Entrepreneur, added: "The word 'introvert' should not appear anywhere near descriptions of disorders or diseases." A reader named Michelle observed that no one says anything like: "Oh, it must be so hard being so extroverted." Artie shared: "I never hear introverts accusing extroverts of being ‘too social' or ‘too outgoing.'" Another anonymous reader: "Is anyone ‘normal?" Capt DJ got a little snarky: "If Introversion is a disease, then can I please get a disability so I don't have to work with extroverts all the time???" Fey chimed in: I'm galled that the APA feels the need to pathologize behavior that is merely somewhere else on the scale of normal variation...." Anonymous added: "The more cynical might suggest the APA are slaves to the drug companies. We have to have new disorders so that new drugs can be prescribed and the market for pharmaceuticals thus expanded."

NA:

Clearly, our story hit a nerve with our readers. What do you think was at the heart of that?

LH: What I pick up on is a collective fatigue on the part of introverts. We’re tired of defending what comes naturally, what works for us and helps us be at our best. It’s ironic that psychiatry – the very profession that produced Carl Jung and liberated so many by enriching our understanding of personality – also has the power to reduce and pathologize those at one end of the personality spectrum. That is a sobering power, and one that needs many checks.

The monetary motive some readers referred to is complex. Mental health professionals provide a valuable service, and the discovery of medications for the treatment of mental health disorders has been a huge advance in the humane care of the suffering, allowing people who were warehoused in hospitals to live normal lives.

And the people who provide care deserve compensation. As a practitioner myself, I know those magic words that may determine whether I get paid: “medical necessity.” If I have a diagnosis, I can show that my client’s care is medically necessary, and the insurance company will pay me to help that person.

In the case of a normal but distressed introvert, it may be more appropriate to diagnose a society that exhibits anxiety reactions when someone wants to be alone. Restoring normality is also the role of psychiatry. I recall working with a client who felt sick, paradoxically, because she was so different from her schizophrenic mother, abandoning father, and baffling family. After assessing her, I told her, “you’re not depressed; your life just sucks.”

She told me later that that is what made all the difference. In her family context, she was weird. In order to sustain her mental health, she needed to be “undiagnosed.” Helping people in the way Carl Jung helped them is a tricky business these days, and we need to address this complexity rather than creating diagnoses to cover every possible distress. I do not envy the job of the APA committee members, and I am glad they came out on the side of sanity and kept introversion out of the DSM-V.

NA: The current proposal to update the DSM includes "detachment" as a headline item under schizotypal personality disorder, saying it "involves withdrawal from other people and from social interactions." It defines withdrawal as "preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact."

We've both written and spoken extensively over the years about introversion as normal – not to mention the huge amount of research and other useful literature. What do you think about the APA's take on withdrawal? Is that, in effect, pathologizing healthy introverts who are more often energized from their quiet time than their social time?

LH: It's important to remember that nothing is diagnosable unless it causes impairment in functioning and/or significant distress for the individual. That said, it seems odd to me that a "preference" for being alone would be considered problematic. To me, preference implies engagement and interest rather than avoidance or incapacity. I do think there are levels of detachment that are indicative of mental health problems, such as a schizoid adjustment in which a person plays out relationships in fantasy rather than incorporating input from others, but there's a diagnosis for that.

Any extreme can limit a person's range, but if we are going to diagnose detachment (which, by the way, is a highly-desired state for a Zen practitioner), perhaps we should consider diagnosing the other end of the spectrum, say "overattachment." Such a syndrome would be defined by the immersion in social situations, highlighted by the preference for being with others; the constant need for social interaction and activity; lack of withdrawal from social contact. Though I'm playing here, I do think we tend to overlook the kind of "withdrawal" that happens for extremely socially-dependent people when they find themselves alone – and it's easy to overlook, because the next time we see them, they're with others again and all better.

NA:

Once again, here’s to healthy introversion!
LH: Yes, to healthy, undiagnosable introversion!

NA:

Copyright © 2012 Nancy Ancowitz