Friday, June 20, 2008

Sad, Sad, Sad

"Man is the only animal that blushes ... or needs to."
--Mark Twain

Social Anxiety Disorder (SAD) affects 15 million Americans, according to the National Institute of Mental Health. Anxiety Disorders as a whole affect 40 million Americans, according to the institute. Drug companies, eager to expand their markets, are now spotlighting the disorder and advertising medications to treat it.

When a running back for the Miami Dolphins, Ricky Williams, was diagnosed in 2001 with Social Anxiety Disorder and put on Paxil, an anti-depressant, it sparked a nation-wide awareness campaign. Williams was then expelled from the NFL in 2004 because he tested positive for marijuana. He then went to work for the drug manufacturer of Paxil, GlaxoSmithKline, a company with much controversy over its sketchy environmental and legal records, and became a spokesperson for Paxil. Williams later returned to football and said in an interview with ESPN that "Marijuana is 10 times better for me than Paxil." Three other anti-depressants, Lexapro, Effexor and Zoloft, were approved for Social Anxiety Disorder in 2003. In 2007 Lexapro alone was prescribed to 27 million Americans.

The Adult Anxiety Clinic at Philadelphia's Temple University, (a widely-known and respected clinic in this field) has developed ways of diagnosing the disorder, describing it as a "fear of being negatively judged by others". But this is relatively unhelpful, seeing as this disorder would appear to describe anyone who is not dancing nakedly in public under the influence of MDMA. Most professionals prefer to describe the disorder as "irrational" then, placing it beyond the bounds of Reason, into the realm of hysteria and professional confusion. The Adult Anxiety Clinic's questionnaire and brief sheet "What is Social Anxiety?" is similarly vague and begs the question of whether the disorder affects as many people as the psychiatric society and the manufacturers argue.

Richard Heimberg, head of the clinic, defines the disorder in his book Cognitive-Behavioral Group Therapy for Social Phobia the same way the DSM-III had, as a "persistent, irrational fear of, or compelling desire to avoid, a situation in which the individual is exposed to possible scrutiny by others and fears that he or she may act in a way that may be humiliating or embarrassing." The psychiatric profession no longer considers social anxiety a phobia, but a disorder. The new term was introduced in the DSM-IV to underscore the pervasiveness of anxiety symptoms and to broaden the scope of the persons that may receive a medical diagnosis. Yet nearly all of the researchers who write the mental illness sections of the DSM manual have been shown to have close monetary connections with drug manufacturers.

If we ask why as many as 15 million Americans are said to have Social Anxiety Disorder, one of the leading indicators to point our fingers at may be the persistence of fears like glossophobia, the 'fear of public speaking', and related phobias that give the impression that Social Anxiety Disorder is more widespread, more pertinent and in need of immediate chemical attention. Most of the discomforts of Social Anxiety Disorder, as indicated by Temple University, are closely related to public speaking and talking in large groups of people.

But the disorder is said to have more of an empirical basis than this. Using MRI scans, Dr. Murray Stein, of UC San Diego, found that when people with the disorder are shown pictures of angry and contemptuous faces, their amygdala (the brain's fear center) lights up with more activity than it does in people without the condition. The amygdala would appear to overreact to anger, but the disorder may happen earlier in the processing of fear. The patients also activate the insular cortex (a part of the brain associated with addiction) more when this happens, suggesting that there is something unnaturally addictive about the feelings and drives behind the anxiety.

The disorder is interpreted by the bulk of the psychological literature as triggered by a complex mix of genes and environmental cues. This is the so-called biological perspective. As Susan Mineka demonstrated in 1986, wild monkeys transmit their fear of snakes to their lab-reared offspring. Mineka and others suggested that human parents similarly transmit their phobias genetically. Individual monkeys also react more strongly to stress if their close biological relatives are anxiously reactive too (Stephen Suomi, Anxiety Disorders of Childhood: 1986), and identical twins have been observed to independently develop claustrophobic disorders (Eckert, Twin Research: Vol. 3: 1981).

That 'anxiety genes' can be passed on to offspring reflects both a sickness deeply embedded in our society and explains the psychiatric desire to purge or medicate populations from exhibiting these traits in order to function well in their societies. Those who are too "irrational" (to use the DSM's phrase) to perform may be perceived as unsuitable mates for others to couple with, and further, will need to be medicated with selective serotonin reuptake inhibitors (SSRIs) which have been linked to suicidiality in adults, but even more so in children, who are prescribed SSRIs at alarming rates.

In a Newsweek interview, Jerilyn Ross, head of the Anxiety Disorders Association of America, said that "People with social anxiety have distorted thinking". This reflects both a layperson's perspective and the perspective of the psychiatric profession. Social Anxiety Disorder and other hysterias as a certain type of 'madness' or 'distorted thinking' merely reflects why the psychiatric profession does not know how to treat it or how to diagnose it. They regard hysterics as people who transgress the laws of their science, "like heretics in the eyes of the orthodox," said Freud.

The sectarian claim that there are people with clear heads and people with distorted heads would quickly fall apart under argumentative pressure. When put in the right circumstances, anyone under the scrutinizing headlamp of the psychiatric doctor may display traits of social anxiety. Psychiatrists often ask patients to interpret a set of pictures, answer loaded questionnaires and otherwise frame the setting with diagnostic devices that make pathologizing unavoidable by their criteria. As reported in the New York Times, psychiatrists are also often compelled by drug manufacturers to distribute their products, go on lecture circuits about them, and receive hefty sums to promote a heavily-medicated society, focusing especially on children and pediatric care.

To say that anyone who views a set of pictures in a particular way is perhaps an indirect method of diagnosing post-industrial civilization itself. In The Myth of Mental Illness, Thomas Szasz argues that 'mental illness' is only a stigmatizing moral judgment, and in fact not a medical diagnosis. If it is true that the psychiatric clinic is merely an office front for an institutionalized moral prescription center, then anyone who steps into a psychiatrist's office may already be diagnosed. To offer your interpretation of Goya's The Madhouse may already mark you for madness in their view, and you may be seeking cures from a poisoned well.

That 'civilization' is the cause of this distress is one of the arguments put forth by the anti-psychiatric movement which developed after the 1960s. Michel Foucault, loosely associated with this movement, argued in Madness and Civilization that systematically institutionalizing the insane or the disorderly is indicative of the way doctors have come to view patients: as turning away from Reason, obversing it, obfuscating it, and becoming more animal-like and therefore treated and medicated in the way that doctors treat and medicate animals. The individual with 'distorted thinking' has taken the place of people formerly excluded on medical/moral grounds, a social institution which developed with the disappearance of leprosy during the High Middle Ages and the need exclude the new 'social lepers' from society.

One thing is clear, Social Anxiety Disorder is supposed to be an intensified form of social shyness. Anxiety as a kind of idiosyncrasy, not a disorder, can make people feel worthless and powerless to move forward with their lives. It can be extremely debilitating especially in an age when the primary criterion for progress, success, etc., is a 'performative' one (Lyotard, The Postmodern Condition: 1979). The famous French hypnotist Pierre Janet made reference to phobia des situations sociales as early as 1903 (Borsch-Jacobson, History of Psychiatry: 2000). Hannah More was the first to use the word in the English language, in 1525, describing a man as dying "without grudge, without anxiete." W. H. Auden published a poem in 1947 called "The Age of Anxiety" ( later developed into a symphony by Leonard Bernstein.)

There is little use contesting the presence of powerful anxieties that have come to dominate the postmodern condition. A fear of other people, a social phobia, might as well be expected from societies where people are alienated from their communities and the fruits of their labor. Idiosyncratic anxiety may be a peculiar historical blend of 'capitalism and schizophrenia' to refer to Gilles Deleuze's phraseology.

In general the biological perspective mentioned earlier is contrasted with the learning perspective, which argues that phobias like this are picked up almost entirely from environmental factors. For example, during World War II constant sirens from air-raids produced conditioned phobias related to the sound of the siren. However, few of these phobias were observed as long-lasting. As the air blitzes continued, the British, Japanese, and German populations did not become more panicked, but rather indifferent to planes not in their immediate neighborhood (Mineka & Zinbarg, Perspectives on Anxiety, Panic, and Fear: 1996). The learning perspective was viewed as incomplete at best.

But there is another perspective that is all too quickly dismissed by the psychiatric profession, and that is the psychoanalytic perspective. It is typically dismissed as an assumption of psychoanalysis that all mystifying symptoms like anxiety were rooted in events during childhood, and for producing "more converts than cures". Modern psychological perspectives focus on the un-falsifiable assumptions of Freudian psychoanalysis, as intensified by the debates between the Adlerian and Freudian schools who challenged each other's assumptions and turned the profession away from psychoanalysis. Modern psychology dismisses the tools developed by these practices, which are, regardless of their assumptions, effective and helpful. This double-standard of praising and blaming to unequal degrees the successes of different curing methods is unbecoming of an instrumentalist science, modern psychiatry.

Psychoanalysis is classically a kind of "talk therapy", or referred to humorously as "chimney-sweeping", that explores the unconscious drives, increases personal awareness, and is less focused on specific symptom relief as the medications are designed to do (Freud, Five Lectures on Psychoanalysis: 1910). Most research on psychotherapy for anxiety disorders focus on Cognitive-Behavioral Therapy (CBT). This is the approach that Temple University's Richard Heimberg advocates. Part of the reason CBT is studied as opposed to other therapies likes psychoanalysis is because it was developed to be easily testable and falsifiable. However, a study that was described by the NY Times has shown that psychoanalysis is highly effective in the treatment of Panic Disorder. Although Panic Disorder and Social Anxiety Disorder are quite different, this study represents an incoming wave of research vindicating psychoanalysis as an effective treatment for anxiety disorders.

Under psychoanalysis, the human subject is said to have a sea of drives and "scenes from recollection" which are largely unobservable but are believed inform our desires and emotions. These artifacts are not judged by their rational or irrational capacity; patients are already assumed to have irrational drives and therefore this alone cannot be clinically conclusive. The boundary between rational and irrational thus overcome, psychoanalysis cannot categorize what is commonly thought of as irrational as 'distorted thinking'. Instead, it attempts to explore all drives by allowing the patient to babble and babble until conclusions and solutions are reached through a personal, dialectic process. Rarely does the psychoanalyst interrupt.

Indeed, most of Freud's own theorizing came from the self-diagnosis of his own unconscious drives. What a psychoanalyst can offer a client in return is principally their own insight and their own experience with similar situations and drives. The bulk of Freud's corpus can be interpreted in this way: as Freud offering his clients an interpretation of their drives in light of the discovery of his own.

For those who wish to have a less patient-to-analyst relationship, there is peculiar form of psychotherapy which was developed by Harvey Jackins in Seattle, WA, called Co-Counseling. It is peculiar because although the clients themselves may be very experienced with psychotherapy, in a Co-Counseling setting, each participant is both a client and an analyst, and there is not a professional diagnostic relationship involved. One client babbles and focuses on 'discharging' their thoughts and emotions, while the other observes and does not speak during this process. The next session they may switch roles. The focus for each participant is primarily achieving emotional competence.

In general the success of psychotherapy can be measured by the personal growth achievements of those undergoing the therapy. Psychotherapy is typically less interesting to drug manufacturers, and thus less interesting to the rest of the psychiatric community. The varied success depends on the competence of the analysts and involvement of the patients, and its performance is less instantly-gratified than the over-praised spark-plug scientism of the psychiatric community. That those intrigued by the "talking cure" could band together and examine themselves and their medical problems would be an attack on the independence and status of the profession.

It has been observed that over the years psychiatrists have become more involved in diagnosing and prescribing medications faster than they prescribe therapies or even offer them. Through any psychiatrist's study they have accumulated such a store of knowledge that remains sealed in a book beyond the patient's understanding. This knowledge is presumably found in the DSM manual, the most-used guide for diagnosing mental disorders in the US. But neither these illnesses nor their cures, we are told, can be explained to a patient seeking help for their anxiety, and typically it is not even on the bottles of the drugs they are prescribed.

For all their knowledge, their training in anatomy, in physiology and pathology, it leaves the psychiatrist "in the lurch," Freud said, when they are confronted by the details of hysterical phenomena. They cannot understand unconscious artifacts or their causes. Just as their patients are laypersons in the face of the 'black box' of the prescription drug container, they too are laypersons in face of the 'black box' of psychosocial phenomena.

1 comment:

Anonymous said...

As an effective medicine, paxil would surely provide you immense relief if you are in the grip of panic disorder, depression or generalized anxiety disorder but it is altogether true that the usage of Paxil occasionally facilitates certain side-effects such as headache, low blood pressure, irregular heartbeat et al. These side-effects can yield serious results if not treated immediately hence take this medicine only on proper prescription.