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Americans Are Being Aggressively Over-Diagnosed

And that's according to Fox News.

The Centers for Disease Control and Prevention released data yesterday showing one in 25 kids in the U.S. aged 12 to 17 is on antidepressants. The data, stemming from an analysis of 12,000 American children and adults, found that antidepressant use in this country increased "nearly 400 percent in the 2005-08 survey period compared with the 1988-94 period, with 11 percent of those over age 12 taking the drugs."

Commentary on Fox News (not my usual media outlet, but Google News had highlighted the article) warned: "Americans are being aggressively over-diagnosed and have become too sensitive to minor health problems... There is an avalanche of patients that for one reason or another have been diagnosed with depression or alleged depression. And it is far too easy to go to any physician and get a prescription for any type of antidepressant."

The CDC data are worth keeping in mind as we consider two recent moves that are guaranteed to push these rates for children higher.

First, the American Academy of Pediatrics (AAP) announced in Boston last Sunday that it has released new guidelines lowering the age at which children can be diagnosed with ADHD, to age 4. The previous guidelines covered children aged 6 to 12, but the AAP claims in its press release, following a study to appear in Pediatrics next month, "Because of greater awareness about ADHD and better ways of diagnosing and treating this disorder, more children are being helped." No mention, of course, about the "avalanche" of 4- and 5-year-olds who are almost certain to be misdiagnosed owing to the elasticity of the DSM criteria, which have been widely criticized, including by the former editor of the diagnostic manual itself.

Second, the same journal, Pediatrics, published a study last Friday claiming that nearly one in eight shy teens may have social phobia. The use of the subjunctive there seems necessary to repeat. I was sent an early copy of the article, owing to a request for commentary on it by Time magazine, and determined after a careful read that its findings are not only unconvincing, but also highly misleading and tendentious. As the article in Time was necessarily brief, I want to explain more fully here how and why I reached that conclusion.

The article in Pediatrics, "Shyness Versus Social Phobia in U.S. Youth," by Drs. Marcy Burstein, Leila Ameli-Grillon, and Kathleen R. Merikangas, gets off on the wrong foot even in its title, which its own findings explicitly contradict. The authors are at least candid about wanting to discredit the thesis that the high diagnostic numbers could in any way be influenced by drug companies sponsoring research on their own products before promoting the results they find favorable in journals they are also helping financially to support—a process I documented extensively in Shyness: How Normal Behavior Became a Sickness (Yale, 2007) from APA papers and drug company memos—that is, from text produced by both psychiatrists and the pharmaceutical industry.

In the same book, I also cited academic psychiatrists pointing repeatedly to just such an overlap between shyness and social phobia. For instance, 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."

In their own article, however, the authors in Pediatrics try to isolate social phobia from shyness ("Shyness versus Social Phobia") when the evidence, including in their study, suggests that the two are so overlapping—for reasons Turner et al documented—as to be almost impossible to distinguish. For example, the first sentence of their "results" section states explicitly, "12 percent of the youth who identified themselves as shy also met the criteria for lifetime social phobia." The actual figure reported in the main article is 12.4 percent, meaning 124 patients in every thousand, or, if you will, considerably more than one patient out of every ten.

Not surprisingly, the authors have to work rather hard to downplay that finding because it explicitly contradicts their thesis. So they go to great lengths to minimize it. The sentence quoted above actually begins, "Only 12 percent of the youth who identified themselves as shy also met the criteria for lifetime social phobia." Later still, they write of their findings (stemming from self-reported data from patients based on DSM-IV criteria), "social phobia affected a minority of youth in this sample and only a fraction of those who identified themselves as shy" (p. 922). Of course 99.9 percent technically would still count as "only a fraction"—the phrase is scientifically meaningless. The bigger problem for the authors is that 12.4 percent is not an insignificant fraction—quite the contrary, and their calling it so is troubling and revealing. Since when did one-in-ten patients not count as a sizeable demographic?

Finally, the study necessarily relies on DSM-IV criteria for social anxiety disorder—and that's of course where the difficulty begins. The criteria themselves repeatedly confuse the disorder with shyness—for instance, by including public-speaking anxiety, fear of going to parties, and eating alone in public. The overlap is so telling that the same manual has to warn clinicians not to confuse the two.

In short, it's not scholars and the popular press who are falsely equating the two phenomena, as the authors of the Pediatrics study try to imply. It's the DSM that is responsible for the category confusion, including because each edition has added more and more criteria to the disorder to lower its threshold. As I reported only last week, DSM-5 looks set to relax the threshold still further by including such routine, run-of-the-mill matters as children "freezing" or "shrinking" when asked to speak or perform in public. That such criteria could be deemed "scientific" in the first place is perhaps the most boggling and disheartening aspect to this.

Rather than decry that medical scandal and question the deeply flawed "kindling theory" of early intervention (the PRIME study of Zyprexa at Yale University was, for instance, "an epic failure"), Pediatrics is publishing articles claiming we can reliably distinguish "shyness versus social phobia" in U.S. youth on the basis of data that explicitly contradict that conclusion.

In short, and however ironically, the article in Pediatrics actually justifies concern about the hazy and increasingly blurred boundary between shyness and social anxiety disorder. Where's the outcry? Look to your media outlets. It's coming from Fox News ... Follow me on Twitter: @christophlane