This week, as part of their series Tales From the Clinic: The Art of Psychiatry, Psychiatric Times carried a short article on social phobia (now social anxiety disorder, SAD, not to be confused with seasonal affective disorder). There is no definition of the condition, only a brief description of a case, so the definition comes from DSM-5 (abbreviations at end). My view is that understanding anxiety is the key to understanding mental disorder [1] - as well as a very large part of the bad side of humanity - so I was interested to see what they had to say.
For some reason, they distinguish between fear and anxiety, where anxiety is a more remote threat and fear is of something here and now. That's wholly artificial, the symptoms are exactly the same. People with SAD become increasingly anxious about mixing socially, to the point where they avoid contact where possible or use drugs to get through it, mainly alcohol. The fear has to be disproportionate and pervasive; getting a bit agitated before a job interview won't qualify. They say the incidence in the US is about 7% of the population, more common in females than males (I'm not convinced on either point), it starts early, is very persistent and can be seriously disabling. Sufferers commonly show other anxiety problems but also depression, drug and alcohol abuse, unexplained physical symptoms and what is called bipolar disorder (I would say it's invariable that people with true social phobia show many other problems).
They don't say anything about causes but point out that many people have no history of significant trauma likely to cause social fears. Often, children showing "behavioral inhibition" go on to develop social phobia. Behavioral inhibition sounds impressive but all it means is that the child is clingy and doesn't like to mix, another apparently explanatory scientific expression concealing a simple description. Treatment, the article continues, is a mix of cognitive-behaviour therapy, lasting between 15-30 hours, and drugs such as antidepressants:
Paroxetine and sertraline are the 2 most impactful drugs in the treatment of SAD, owing to their exceptional relapse prevention rates and a 10 to 50 mg/day dose of paroxetine is considered the gold standard for the best response rates (>50%) if overall adverse effects are taken into account.
I hate that expression, "gold standard," all it means is "I'm an expert so don't question me," but why go straight to psychiatric drugs? Well, that's what psychiatrists do, otherwise they can't justify themselves but also it's because they don't have a formal model of what social phobia/anxiety disorder actually is. If pushed, they mumble about neurotransmitters and genes and temperament, as they do on page 205 of DSM-5, but the correct answer is buried in the diagnostic criteria:
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. leading to humiliation and rejection).
That anticipation is, of course, the very essence of social phobia. It's the thought "I could make a fool of myself" that does the damage. What sort of fool? An anxious, trembling, stuttering, sweating type fool. Anticipation of trouble is the central mechanism to all phobias, but this needs to be explained.
Anxiety is the psycho-somatic response to the perception of a threat. The whole point of the anxiety response is to get you ready to deal with the looming threat. Anxiety is universal, in that every creature higher than bacteria shows some sort of threat response, otherwise they wouldn't be around for long. A threat is always in the future, coming at you, and the closer it gets, the higher your anxiety level goes. This is the classic "fight or flight response," where your body and mind get ready for some serious action. Anxiety is not just a racing heart, it's also a racing mind. It doesn't matter how fast your heart is racing when you see that tiger shark heading at you, if your mind is sluggish, you'll be breakfast.
Psychiatry wants to split the unitary threat response into dozens of separate anxiety disorders but there's only one sort of anxiety, the scary sort. There's not one brand of anxiety for cat phobia and another for acrophobia (fear of heights), it's all the same. I used to keep a list of phobias people mentioned, including dolls' eyes, bubbles, rust on boats, puppies (but not big dogs) and, amazingly, nipples. The point is: the fears are irrational, they bear no relationship to what is actually dangerous.
However, that doesn't mesh with the idea that each mental disorder has a specific genetic cause, which is the unstated agenda of mainstream psychiatry. Why bother looking for separate genes for slightly different conditions? Because their anti-mentalist ideology doesn't allow them to lump it all together and find the common mental element that unites them. As good positivists [2], the one thing they will not accept is that mental disorder could be mental in origin, even though they've already walked past the cause: people fear they will "show anxiety symptoms" and be judged.
However, social disapproval isn't the really scary bit. The core of any anxiety state is that sufferers have become frightened of their own anxiety symptoms: anxiety feels so bad that they fear it. Most important, they fear it won't stop, because that has been their experience. That's why people are scared of frogs, even when there's nobody around to laugh. They're not saying "I'm scared of frogs," because they all start with "I know they're harmless and I know they can't hurt me but..." At that point, the therapist butts in: " ... but you're terrified of frogs. Yes, I hear it all the time but actually, you're not scared of frogs in the slightest. You're scared of how you'll feel if you go near a frog, which is completely different. You fear your own fear state. And the closer you get to one, the more real that seems, so the fear builds up and up until you have to get away. Then you blame poor froggy."
With this formulation, it becomes clear that (a) all phobic and panic states have the same mechanism, (b) it's got nothing to do with genes and (c) using antidepressants to suppress a belief state is useless. That's why their "response rate" is only a bit above 50% after six weeks or so.
In general medicine, if symptoms are troublesome and /or destructive, e.g. pain in acute injury, inflammation of joints in arthritis, irritating cough with asthma, then we suppress them. We don't put people on psychiatric drugs to dull them and stop them complaining about the symptoms. In dealing with the anxiety of a phobia, why does psychiatry not follow this example? If the shaking, sweating, racing heart and churning stomach, better known as the adrenaline response, are a problem, why not deal with them directly? We can do that, we simply give a drug to block these symptoms directly, which is what adrenaline blockers do. Their advantages are they are about 97% effective, not 50%; they work immediately, not in six weeks; they don't cause weight gain or drowsiness; they don't wreck your sex life; and above all, they are non-addictive so people can take them when they need them. Finally, they're off-patent and they cost practically nothing (In India, which has a huge, world-class drug industry, 100 tablets costs about 84c Aust, or 50c US). For a person disabled by social phobia, or any phobia, that's a pretty good deal.
That good news is, however, an enormous disadvantage for drug manufacturers, which is why the article didn't mention adrenaline blockers. Instead, it was all about beating up business for a new and, we can be sure, fearsomely expensive form of treatment that is also no better than 50% effective. A steroid nasal spray has been developed, based in the mysterious chemistry of pheromones. It sounds impressive except the original article uses language remarkably similar to the beat-up around ketamine, psilocybin, MDMA (ecstasy), TCMS and so many others [3]. Time will tell, but what counts here is the process used to market it.
So far in the article, their science of psychiatry is stumbling and we haven't seen any evidence of their "art of psychiatry." What we do see, however, is how psychiatry is trying to grab yet another large sector of the community and turn them into patients. The Psychiatric Times article follows the standard format for creating a new psychiatric market: (a) panicky broadcasts that the disorder is mostly unrecognised, the implication being "and you or your children could have it," (b) it causes vast but silent disability and is rapidly getting worse because (c) if it's not treated, it leads to all sorts of disasters, especially in children but (d) wonderful treatments are available and (e) even better ones are on the way. This is the standard process for converting a normal state to a "disease state." Yes, true social phobia is seriously disabling and, under the influence of the internet and gaming, it could well be getting worse but that's not grounds for panic, or for wasting money on expensive treatments.
First, we are told, social anxiety is largely unrecognised because everybody confuses it with everyday "shyness, introversion, and temperamental disposition." Despite this being a "scientific" article, none of these things are defined. In ordinary use, "shyness" is a label, a word we attach to somebody as a behavioural descriptor: "Yes, he's always been shy, takes after his aunt Ethel but otherwise he's fine." It just means "doesn't mix well, not very confident, tends to blush and stammer with attention," etc. The author doesn't say anything about how the person feels inside because if you talk about emotions, it is obvious that shyness isn't an illness in any sense of the word. It's mild anxiety and, with a bit of training and experience, people get over it, but the drug companies don't want you to know that because expanding their income depends on you not knowing it.
"Introversion" and "temperamental disposition" are also behavioural descriptors but in this case, they're the same thing because "introversion" just is a "temperamental disposition." They're personality factors and, as everybody knows, personality isn't an illness and doesn't respond to psychiatric "treatment." Again, these terms say nothing about how the person feels.
However, that sort of common sense approach isn't good for business: all those potential patients are getting away. With social phobia, the Big Pharma-Big Psychiatry axis are trying to do what was so successful with "depression," where normal sadness and grief were turned into the dread disease of "major depression" [4]. This has generated many hundreds of billions of dollars in sales for drug companies, who have sprayed some of this money over academic psychiatrists who spread the word that "Depression is out to get you," as they did with ADHD and with ASD and Premenstrual Dysphoric Disorder. Now they're doing the same with shyness and socially clumsy teenagers (who wasn't?): medicalise it, turn it into a disease, make parents feel guilty that their children may need treatment, and so on (here's an interesting article on how to turn a normal child into a mental cripple; luckily, it didn't work).
And that's it. The Disease-Mongers' Playbook strikes again. So simple, so effective, so profitable, because people always fall for it.
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Continuing with the forthcoming volume, Theories in Psychiatry: Building a Post-Positivist Psychiatry, due in July, Part II asks whether philosophers have any ideas on how to construct a model of mental disorder. Spoiler alert: they don't. Hardly any major philosophers consider mental disorder, but the real question is whether their work can be turned into something useful to the rest of the world's population. However, the exercise is worthwhile because it tells us something about philosophy that seems to be a fairly well-kept secret. We start with the universally-acclaimed "public intellectual Numero Uno," Noam Chomsky, or St. Noam to his adoring public.
Chomsky is said to have started the "cognitive revolution" in psychology, in that what the behaviorists JB Watson, BF Skinner, HJ Eysenck and so many others threw out (the mind), Chomsky picked up, dusted down and put right back in the centre of things. Chomsky argued that we cannot assemble a plausible theory of human behaviour without including a mental element. He meant mental as mental, not as biochemistry. Trouble is, it turned out that he couldn't do it, not least because he only addressed language, ignoring emotion, personality and everything else that distinguishes us from automatons. Chomsky's work was only half a theory of mind, the boring half. Even that, I argue, failed, but we should give him an E for Effort.
Chomsky is at MIT, on the banks of Boston's Charles River; a few km north, Tufts University is home to another famously talkative philosopher, Daniel Dennett. Relations between the two don't seem very cordial but that's academia for you: as Wallace Sayre said, “Academic disputes are the more bitter because so little hangs on them.” Dennett is notorious for the virulence of his hostility toward anything that smacks of dualism, the notion that the universe has two distinct parts, the physical and the mental. "Somehow," he insists, "the brain must be the mind." He assembles very wordy, jolly accounts of how this comes about but it's on the "somehow" that I argue he runs aground. I say his project fails, but for the remarkable reason that, in the end, he openly embraces dualism to complete his explanation of his non-dualist mind.
Does that sound contradictory? That's my case, that he contradicts himself but, true to form, he rejects this virulently. We'll just have to see who's right but these two philosophers illustrate an interesting historical point: that each age has its philosophical/psychological "heroes" who dominate discussion among the chattering classes but, as soon as they pass on, they quickly fade from public awareness. In their time, Skinner and Eysenck were Big Names, they provoked intense public debate and their theories were scrutinised in every journal more pretentious than, say, motoring mags. Their ideas were kept alive by the force of their personalities but, without regular blasts of hot air from the Great Men, their carefully-constructed balloons collapsed. They're both getting on so we'll see, but the take-home point is that neither of these hugely influential thinkers has anything for psychiatry. Oh well, we press on. But what's the well-kept secret about philosophy of mind? It's secret, you'll have to wait a bit.
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References:
1. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press.
2. McLaren N (2023) Diagnosing psychiatry's failure: The need for a post-positivist psychiatry.
Chapter 4 in Practical Alternatives to the Psychiatric Model of Mental Illness: Beyond DSM and ICD Diagnosing. London: Ethics International Press: Critical Psychology and Critical Psychiatry Series, Vol III.
3. Monti L, Liebowitz MR. Neural circuits of anxiolytic and antidepressant pherine molecules. CNS Spectr. 2022;27(1):66-72.
4. Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.
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Abbreviations:
ADHD: You're kidding me.
ASD: Autism Spectrum Disorder. We'll talk about "spectra" another day.
DSM-5: Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association.
MDMA: 3,4-methylenedioxymethamphetamine, a derivative of meth, or ice, commonly known as ecstasy, a nasty party drug.
TCMS: transcranial magnetic stimulation, latest-but-one cab off the rank in the eternal search for a physical treatment of the mental matter known as depression.
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I know practically nothing about him, he's not taken seriously by people who take the concept of mind seriously. But if he likes Jung, then I'm afraid he's lost me.
They can, but there is a lot of work being done to make sure they don't know there is a contrary opinion. Students and trainees in psychiatry are never exposed to critical views.