Harvard Gazette
April 30, 2009

By Corydon Ireland

Harvard News Office

Not long ago, a majority of Americans described themselves as “shy,” a condition of reticence or caution that for ages just seemed natural.

In a discourse on blushing, Darwin thought of shyness — “self-attention” — as an adaptive trait. In a poem, Emily Dickinson described it as something that follows emotional pain: “a formal feeling comes — / The Nerves sit ceremonious, like Tombs.”

But in the past two decades, shyness has darted out of the realm of the ordinary and into the medical books. Now a shy person might be suffering from “avoidant personality disorder” or a list of other anxiety-related mental ailments first described in 1980.

That was the year an expanded edition of the “Diagnostic and Statistical Manual of Mental Disorders” was published — the third edition of the American bible of psychiatric disorders. (A fourth has since appeared.)

Of the 112 new disorders described in DSM-III, seven related to shyness or social anxiety.

In 1979, shyness had no medical status, but by 1993, it had been elevated to the third-most-common mental disorder in the United States after depression and alcoholism. And the treatment? Antidepressants — for which 200 million prescriptions are written every year, earning drug companies over $10 billion annually.

The transformation of shyness from blushing to a bona fide illness is an example of medicalization — a complex social, moral, medical, and economic phenomenon that in the past century has widened the definition of disease.

It was the subject of a four-hour Harvard conference last week (April 22) in Emerson Hall, jointly sponsored by the Humanities Center at Harvard and the A. Bernard Ackerman Endowment for the Culture of Medicine. Presenting lectures and sitting on panels were a gathering of experts in history, the law, medicine, social studies, and literature.

Christopher Lane, a scholar of Victorian literature at Northwestern University, offered up a lecture on the medicalization of shyness, drawn from his bestselling 2007 book, “Shyness: How Normal Behavior Became a Sickness.”

In it, he quotes Darwin on blushing, and Dickinson on nerves sitting ceremonious. Lane also wonders aloud on what the medical fate of two other famously shy writers (Henry David Thoreau and Nathaniel Hawthorne) might have been in a medicalized world.

How did bad breath become “halitosis,” Lane asked, looking out at the audience of about 80, and how did impotence turn into the formalized “erectile dysfunction” — once an accepted consequence of aging that is now the stuff of daytime television?

Medicalization is not the easiest word to understand, he said, but it is the best one to explain so far “a juggernaut which no one seems able to stop.”

Behind that juggernaut is a culture-accelerating blend of medicine, marketing, and perceived need that Allan Brandt called “inexorable” and culturally pervasive. (Brandt, who helped introduce the event, is Amalie Moses Kass Professor of the History of Medicine and dean of the Graduate School of Arts and Sciences.)

“Before you sell a drug,” said Lane — skeptical of a well-oiled U.S. medicalization machine, “you have to sell an illness.”

Harvard Provost and Professor of Neurobiology Steven E. Hyman, who helped introduce the event, acknowledged the dark side of medicalization. Drug companies do sometimes “exploit our credulity in order to turn problems of ordinary living into dread diseases,” he said.

And the same companies are capable of making a “trivial chemical modification” to a drug that is about to go off-patent — and reintroduce it as a treatment for something else.

But there is another side to medicalization, said Hyman — the promise of new research and therapies for neglected diseases. (Alzheimer’s, he offered, was once just dismissed as senility.)

“It’s very easy to demonize in an unalloyed way the forces of medicalization,” he said — but “there are clearly benefits, liberating benefits, for reconceptualizing some areas as illness.”

The Harvard conference explored the wide gray zones of medicalization with other case studies.

McGill University social scientist Jennifer Fishman looked at a hybrid commercial-medical world that is stretching the boundaries of “normal” in aging. Her research explores how the sexual dysfunction that sometimes accompanies normal aging has been commodified — made profitable — in the concept of “successful aging.”

Fishman’s investigations, in part, touch on how new diagnoses often emerge in tandem with new drugs; how drugs related to sexual performance have gender implications; and how modern marketing has changed our understanding of medical information.

Direct-to-consumer drug advertising — legal in the United States and New Zealand — “cuts doctors out of the loop,” lamented Homi Bhabha, director of the Humanities Center, who introduced the conference. The smooth, soothing voice-overs in medical commercials seem so empathetic, he said, that you feel “better looked after by your television than your GP.”

Harvard assistant professor in the history of science Jeremy Greene — a physician-historian who studies the pharmaceuticals industry — said conditions that get treated are sometimes simply dependent on what drugs are available.

As a case in point, he talked about the “therapeutic expansion” of cholesterol-lowering drugs. With the introduction of statin drugs starting in the 1980s, Greene offered, cholesterol was revived as a key risk factor in heart disease. (In the decade before, its relevance had been downplayed.)

Other speakers, including Hyman, touched on the wider social realities of medicalization. (The session was chaired by Arthur Kleinman, the Esther and Sidney Rabb Professor of Anthropology and a professor of medical anthropology and psychiatry.)

“Just as medicalization spreads through life, it spreads through the law,” said Martha Field, Langdell Professor of Law at Harvard Law School.

In criminal law, medical debates have arisen over, among other issues, compulsory sterilization and — more dramatically — over the insanity defense. In 1981, the trial of John Hinckley Jr. for the attempted assassination of President Ronald Reagan turned into “a great battle of experts,” said Field.

When Hinckley was found not guilty by reason of insanity, she said, the same strategy of defense fell into disfavor with juries.

Field also touched on other arenas of law affected by medicalization: disability, reproductive rights, assisted suicide, the murder of defective newborns, the biological underpinning of homosexuality, and identity disorders that seem to demand surgical intervention.

Nancy Krieger, professor of society, human development, and health at the Harvard School of Public Health, offered an “ecosocial perspective” on medicalization.

Public health, she asserted, often adopts a “narrowly bio-medical perspective,” neglecting what her research has shown: that “injustice, not biology,” is the source of health inequities.

Some historical perspective came from Charles Rosenberg, Harvard’s Ernest E. Monrad Professor of the Social Sciences.

“Disease specificity,” he said, is “a very recent historical phenomenon” — and being more specific about naming diseases may have thrust us into a hundred ye
ars of an “increasing bureaucratic imperative” of medicalization.

“Disease perspectives are narratives,” and are subject to continuing fluidity, said Rosenberg.

But humans remain “individual moral actors,” he said. “We are shaped by our diseases. We are not reduced to them.”