Diagnosis

I am writing this post as a response to a comment posted by medical blog in my previous post, More on So-called Bipolar Disorder.

In the summer of 2001 I became very ill.  The symptoms were exhaustion and mild nosebleeds. I went to three different practitioners, but they all were dismissive of my concerns, assured me that I was in good health, and sent me on my way.   On August 8th of that year I was admitted to the hospital in Greeley, Colorado with complete kidney failure.  The nephrologist at the hospital gave me the diagnosis that had eluded the earlier doctors:  Wegener’s Granulomatosis – a rare autoimmune disease that attacks lungs, kidneys, and airways. I have been on dialysis every since.

The reason I tell this story is to illustrate the meaning and significance of a medical diagnosis. In my case there were certain signs and symptoms.  For instance, I told the doctors that I was tired and that this was not characteristic of me.  I told them of the nosebleeds.  And they could see that I was dragging.  By the time I got to the second doctor, I was also vomiting and having difficulty sleeping.

Now the point is that until I got to the hospital in Greeley, there had been no diagnosis.  One doctor said:  “maybe you’ve got the flu?”  But it didn’t feel like flu, and this tentative diagnosis wasn’t very convincing.

When we ask for a diagnosis we are asking for an explanation.  So if you‘re very tired and you’re spitting up dreadful-looking phlegm, a doctor might diagnose pneumonia and would be able to substantiate this diagnosis through observation and lab tests.  And – and this is critical – he would be able to show a clear causal link between the pathology and the symptoms.

In my case, the diagnosis of Wegener’s Granulomatosis explained the exhaustion (increased toxicity due to kidney failure) and the nosebleeds (Wegener’s Granulomatosis is believed to be triggered by an airborne pathogen and so the immune system becomes particularly active in this area).

The key is explanation. A good diagnosis pinpoints the pathology, explains the symptoms, and directs treatment.  This is the model that has lifted Western medicine out of the charlatanistic quackery that predominated prior to about 1880.  Modern medicine is remarkably successful precisely because it is based on an understanding of the pathology involved.  Now obviously, as in my case, it sometimes isn’t easy to make a diagnosis, but in the vast majority of cases, people seeking medical help receive an accurate diagnosis early in the process, and this diagnosis guides and directs treatment, usually with a good deal of success.

Now let’s consider the so-called mental health diagnoses.  Take the condition known as Attention Deficit Hyperactivity Disorder.  The American Psychiatric Association says that this is a mental illness. In other words, ADHD is a diagnosis.  And they list the symptoms of this diagnosis.  I have reproduced these so-called symptoms in an earlier post, and it’s not necessary to reproduce them here, but here are three fairly typical items from the list:

  • often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • often leaves seat in classroom or in other situations in which remaining seated is expected.
  • often runs about or climbs excessively in situations in which it is inappropriate…

Now what the APA have done is this:  they have asserted that these are the symptoms of the mental illness that they call ADHD.  Now if this means anything, it should mean that ADHD is the explanation of these misbehaviors.  And this is precisely how the so-called diagnosis is used in practice.  When a parent asks why his child is so unruly and undisciplined, the reply he is given is:  because he has ADHD.  The putative mental illness is routinely proffered as the explanation – as the underlying pathology which explains why the child is so misbehaved.

But in fact if one examines the matter further, one finds no substance to this so-called diagnosis.  ADHD is nothing more than a name for this kind of misbehavior.  The acid test here is the question:  how do you know he has ADHD?  And the only possible answer is:  because he is so unruly and undisciplined.  The only evidence for the so-called diagnosis is the very behavior it is supposed to explain.

Real diagnoses involve real pathology that one can identify, test for, and hopefully ameliorate.  Wegener’s Granulomatosis, for instance is a real disease.  And it is recognized as a diagnosis today because Dr. Wegener, a research pathologist working in Germany in the 1930’s, noticed certain microscopic anomalies in corpses he was dissecting.  He began to tie these anomalies with symptoms observed before the individuals had died.  His work was interrupted by the war, but after the war he refined his observations, and the diagnosis was firmly established.  At first there was no treatment for WG – it was effectively a death sentence – but gradually drugs became available, and today the disease is eminently treatable, though because of its rarity, the diagnosis is often missed (as in my case).

In contrast, consider the so-called diagnosis ADHD.  Prior to 1950 this diagnosis did not exist.  Today it is deeply embedded in psychiatric practice, and indeed in our collective consciousness.  This change occurred – not because of a discovery – but because an APA committee decided that ADHD is an illness.  As preposterous as this sounds, it is exactly what has happened.  In the six decades from 1950 to the present, the primary business of the APA has been redefining the ordinary everyday problems of living (that our ancestors tackled using ordinary time-worn tactics) as mental illnesses.  And this has been done in collaboration with the pharmaceutical companies for one reason:  profit – the selling of prescription slips and the selling of drugs.  Psychiatry has degenerated into nothing more than drug-pushing.  And the process of pathologizing normal problems of living continues.  The much-heralded DSM-5 promises even further inroads in this direction.

The fundamental problem with the APA’s approach emerges from their definition of a mental disorder:

… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress…or disability…or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.  (DSM-IV-TR, p xxxi)

If you examine this definition carefully, it is clear that it means nothing more than:  any significant human problem.

It’s a castle built from sand.  The logic is as follows:

  • Any human problem is a mental disorder.
  • X is a human problem
  • Therefore X is a mental disorder!

As facile and ridiculous as this sounds, it is exactly what has happened.  The simple assertion that childhood misbehavior is a mental illness explains nothing.  It is simply a device used to legitimize drugging these children.

And the real causes underlying these problems are never even pursued.  Parents are off the hook; the school is off the hook; the community is off the hook. And the cash registers at the pharmacy go ker-chung.

And similar considerations apply to all the other DSM creations.  Depression is not an illness.  It is a feeling we get in response to a major loss or when things are not going well for us.  It has been pathologized by the APA and the pharmaceutical companies for gain.  The so-called bipolar disorder is not an illness – it is largely rudeness and irresponsible behavior – again pathologized for gain.

It is said that the drugs work, so why quibble?  Well the simple answer is that they don’t work nearly as well as the psychiatric hype would have us believe.  But this post is already too long; perhaps we can pursue this another time.

Once again, apologies to my regular readers for the repetition.  Medical blog, if you’re still reading, I can appreciate how a medic, schooled in the rigors of scientific research, might view all this with a measure of skepticism.  It’s a great deal easier to dismiss me as a crank than to face the alternative:  that modern psychiatry is an enormous hoax which is draining dollars from genuinely needed services and undermining notions of self-help and personal responsibility that are keystones of a thriving society.  Please feel free to come back on any of these issues.  It’s not just a question of trying “harder and smarter.”  Some of the problems that confront people are truly overwhelming and require outside help.  But they are not illnesses and the help needed is not drugs.

 

 

  • cathryn

    Phil,
    Good article on ADHD. I was diagnosed with that when I was a kid, they put me on meth basically at age 13. They ended up switching my diagnoses when I was older to bipolar. But this article is basically saying that’s just an excuse for my rude and obscene personality? Psychiatry become excusology right here huh?
    I am very skeptical of ADHD meds. I remember being very depressed on them and people all around america are abusing them. Do you realize how many college students use adderal or ritalin on a routinely basis to complete their homework assignments in california??? I woud like to know this statistic because from personal experience I would say I know more people who are on it then not. Not a good direction we are heading that is for sure.

    You are very controversial, i like your website. I am glad I found it.

  • Sam

    Catheryn,
    In my opinion, an important aspect of Behavioral Psychology is that it eliminates the concept of “evil” behavior, replacing it instead with “unwanted” behavior.

    Without evil, there is no reason to blame anyone. And without needing to blame people, there’s no reason to find excuses. Instead, behaviorism seeks to explain behavior, with the intention of creating a society where “unwanted” behavior is reduced and “wanted” behavior is increased.

    So when you say that this article says that your diagnoses of ADHD and bipolar disorder “is just an excuse for my rude and obscene personality,” what you’re saying is that the article is blaming you for having a rude and obscene personality, and blaming the doctors for letting you get away with it. But that’s not the case.

    If a person believes the tenets of the scientific perspective of behavioral psychology, then that person must attempt to apply its conclusions to what actually happens in the world. Behaviorism says that people’s behavior is a result not of “personality” or “evil” or “mental illness,” but rather three things: the learning history, the current stimuli present, and the current level of satiation/deprivation.

    I think it’s difficult to approach behaviorism with a purely scientific viewpoint, free from the morality and values of society. Society says that if something happens, it’s someone’s fault. It’s your fault for behaving poorly, and it’s the doctor’s fault for letting it happen. It’s really easy, having learned about behaviorism, to take the next step and either say “it’s my parents’ fault for training me to behave poorly,” or “I get a free pass because it’s not my fault.”

    But neither of these are a good way to view the world. It’s no more your parents’ fault for training you to have bad behavior than it is their parents’ fault for training them to train you, and it’s not their fault any more than it is their parents’ fault, and on and on. And that’s not even beginning to look at the huge role peer groups play in a person’s development.

    The second way is also incorrect – no one needs a free pass because everyone already has gotten in, as it were. We’re all just people who behave in the way we’ve learned to. However, the fact that your unwanted behavior is a product of how you have learned to behave does not change how other people in society will judge you. (Even behaviorists can be pretty thoughtless sometimes, after all.) Regardless of whether it’s unwanted or evil, it’s still viewed by others as “rude and obscene.”

    Both of them seek to use behaviorism to reinterpret current beliefs about morality. But, like with any scientific theory, it’s not a gear to be put into the moral mechanism, but rather a lens through which the image of morality must be viewed to see it clearly.

    In other words, if you have unwanted behavior, that’s really too bad, but it’s nobody’s fault. Thankfully we understand why it happens, so we’re able to actually understand how to replace it with wanted behavior.

  • Flightfire

    I was following your argument right up until you stepped over the line. I agree that there are certain diagnoses that are somewhat specious like ADHD and behavioral disorders. But I was shocked when you called Bipolar disorder “largely rudeness and irresponsible behavior.” Does this same standard apply to schizophrenics? Are they supposed to just snap out of their delusions and behave better without the help of anti-psychotics? Does the same standard apply to children with autism?
    Psychiatry is simply doing what medicine did before the advent of anatomic study and pathology. They are cataloging and characterizing patterns of mental disease because our understanding of the origins of behavior is so limited. I have no doubt that the underlying pathology of the majority of the diseases in the DSM will be explained at some point, we’re just not smart enough to figure it out at this point.
    Dr. Wegener built off the work of other scientists who noticed the disease far earlier than he did. He just happened to put the pattern together. He was also a Nazi, so don’t be too quick to lavish compliments on the old pathologist.

  • Cathryn,

    Suppose a physician were to decide to devote his career to the detection or treatment of the flu. So he learns what he can about the disease, encourages early intervention, etc.. And let’s say he starts to be very successful. Anybody who has flu in the area comes to him and he treats them successfully.

    But his endeavors are limited by the disease itself. He can’t create new cases. With the so-called mental illnesses, no such limitations apply. The so-called diagnostic categories are as flexible as an unscrupulous psychiatrist can want them to be. The result is what you describe today.

    I suppose my stuff is somewhat controversial today. Though when I started – back in the 60’s – behaviorism was fairly mainstream, and research in all these areas was flourishing. But research has been hijacked by the pharmaceutical companies, and behaviorism has been marginalized. Hopefully it will re-emerge as people start to see the present drug-pushing for what it is.

    Best wishes.

  • Sam,

    This is an excellent piece on the psychology of blaming. Keep up the good work.

    Best wishes.

  • Flightfire,

    Thanks for your interesting comment.

    Let’s start with the condition known as bipolar disorder. The APA criteria for a manic episode are listed in the DSM, and when I describe the so-called bipolar disorder as rudeness and irresponsibility, I think I am accurately describing the APA’s own criteria.

    Here’s a quotation from DSM-IV-TR, p 359:

    “Gambling and antisocial behaviors may accompany the Manic Episode. Ethical concerns may be disregarded even by those who are typically very conscientious (e.g., a stockbroker inappropriately buys and sells stock without the clients’ knowledge or permission; a scientist incorporates the findings of others). The person may be hostile and physically threatening to others.”

    and from p. 358:

    “Individuals may talk nonstop, sometimes for hours on end, and without regard for others’ wishes to communicate. …speech may be marked by complaints, hostile comments, or angry tirades.”

    and also on p. 358:

    “Expansiveness, unwarranted optimism, grandiosity, and poor judgment often lead to an imprudent involvement in pleasurable activities such as buying sprees, reckless driving, foolish business investments, and sexual behavior unusual for the person… The individual may purchase many unneeded items, (e.g. 20 pairs of shoes, expensive antiques) without the money to pay for them. Unusual sexual behavior may include infidelity or indiscriminate sexual encounters with strangers.”

    So when I describe “bipolar disorder” behavior as rudeness or irresponsibility, I think I’m providing an accurate reflection of the APA’s own criteria. What name would you give to these behaviors?

    To guard against misunderstanding, let me clarify that when I describe “bipolar” behavior as rudeness and irresponsibility, I am describing not explaining. This is a very important distinction. Explaining a behavior usually requires a detailed knowledge of the individual’s history and circumstances. Describing behavior is usually not so challenging – we simply observe and describe. One of my major criticisms of the APA’s system is that it is a descriptive system masquerading as an explanatory one. If you were to ask a psychiatrist why an individual were behaving in such a rude and irresponsible manner, he would reply: “because he has bipolar disorder.” If you were to ask, “How do you know he has bipolar disorder?” the only possible reply is, “because he has been behaving in such a rude and irresponsible manner.” The term “bipolar disorder” is just another way of saying rude and irresponsible. It adds nothing by way of explanation, and in fact does great disservice because it gives the impression of an explanation.

    There is one clarification that I need to make. I have never said that people should just “snap out of” their various dysfunctional and counterproductive habits. Nor have I ever said that people should stop taking drugs.

    My primary concern is that we call spades spades, and that we recognize the psychiatric sand-castle as a wrong turning in human history.

    You say that :

    “Psychiatry is simply doing what medicine did before the advent of anatomic study and pathology. They are cataloging and characterizing patterns of mental disease because our understanding of the origins of behavior is so limited.”

    Now this is a fairly typical bio-pharma-psychiatric fall-back position. But it is simply false. They are not just cataloging and categorizing – they are purporting to explain unusual and disturbing behavior. The so-called mental illnesses are routinely presented by practitioners and by the APA itself as explanatory, which they emphatically are not.

    Secondly, our understanding of the origins of behavior is NOT so limited. In fact, it is an extremely well developed body of knowledge thoroughly grounded in scientific method, and validated and re-validated through rigorous experimentation. This entire body of knowledge has been systematically marginalized by the APA precisely because it shows clearly and unflinchingly the spurious nature of their conceptual framework.

    I didn’t intend to get into a defense of the late Dr. Wegener. I was simply contrasting a real diagnosis (such as Wegener’s Granulomatosis) with the spurious variety in the DSM, and the work needed to identify the former (regardless of who did it) with the inane, committee activity of the APA. I had heard that Dr. Wegener was a Nazi, but I don’t know if this is true. Regardless, I, and many other victims of this devastating disease, am grateful to him and his collaborators for their pioneering work in this field.

    One final point: children with autism. I have had little or no professional involvement with individuals who meet the criteria for this condition. An examination of the criteria would lead one to believe that it is fundamentally behavioral. Indeed, when I was a student (back in the 60’s) this was how it was conceptualized and treated. Since then various neurological etiologies have been proposed, but my experience with this group is so limited that I don’t have a firm position. I believe that research in the behavioral area has been hi-jacked by the pharmaceutical companies, through having paid “consultants” on the journal editorial boards, scuttling projects that might cast doubt on the pharmaceutical position, selecting for publication only those papers that support the pharmaceutical position, and blatantly massaging (i.e. distorting) data to make it conform to pharma’s requirements. It’s difficult to know what to believe any more.

    So there it is. I’m sorry that you find my position so shocking. In fact, I believe mine is the parsimonious position. I say that misbehavior is… misbehavior. It is the APA and their pharmaceutical allies who, without any evidence, say that misbehavior is really an illness! That’s an extreme position, which our grandparents would have considered funny. The widespread acceptance of this notion is a tribute – not to any great discovery, but rather to the massive promotional campaigns maintained by the pharmaceutical companies and by the APA for the past several decades.

    I’m very glad that you wrote. I hope you will browse around the blog. In particular, take a look at the posts on Schizophrenia. Please come back if there’s anything specific you would like to discuss.

    Best wishes.

  • Hello Phil, I am doctor (qualified UK 1992), now working in Australia in a rural hospital as a generalist.
    I read most of your blog entries this weekend.
    I have to tell you that the hoaxes perpetrated by the therapeutic industry (basically self-interested pharmceuticals companies and biassed doctors) do not end with the psychs. The story of hypertension is something I could bore you with….
    It is becoming so ridiculous in the mental health sphere that I wrote a bit of fiction about Homeobarometric Alternation which is a therapy invented to treat depression and rests on the theory that the semicicular canals have a primitive limbic association which influences our mood. It all ends up with solemn nurse practitioners in the psych wing escorting “depressed” inpatients for sessions bascially going up and down in the elevators 70 or 80 times per session. But it has as much science to it as ECT which is what the punchline is….
    My brother and my best friend are consultant psychiatrists. They are trapped by this onslaught from Big Pharma, coached patient interest groups (In Australia we have Beyond Blue, inter alia) and para-psych practitoners e.g. life coaches etc, and the media.
    The question after all my rambling is: what are you, what am I going to do about all this ?
    I get release in satire (a la Stanislaw Lem’s oeuvre) My next little ditty is about a nobel prize candidate who is researching post mortem psychiatry.
    Anyway, nice to know there are some kindred spirits. Sounds like it’s way worse in the USA.

  • Nanu,

    Thanks for your interesting and thought-provoking comment. I can certainly imagine that Big Pharma has its tentacles into mainstream medicine. Indeed, we see examples of this all the time. Right now statins are being pushed vigorously.

    It’s interesting what you say about the etiological significance of the semi-circular canals. Possibly young people who play radios too loud are “self-medicating?” Of course, for a therapy to be successful, it has to be expensive – so the elevators would have to be equipped with special chairs, monitoring equipment, etc.. After all, psychiatry is a business!

    I’m a retired psychologist. I spent my career working in prisons, mental health centers, addiction units, private practice, and nursing homes. Over a 30-year career I spoke and wrote about the spurious nature of the so-called mental illnesses.

    What can we do? My personal answer is to write this blog. It’s not much, but I have serious health problems and it’s about the best I can do. I like the analogy of the emperor’s new clothes. Most people are taken in. They’ve been told that the emperor’s garments are wonderful and resplendent, and they feel too overawed or respectful to say otherwise. But cracks are appearing in the edifice, and as more people like yourself speak out, perhaps the word will spread – the emperor has no clothes; the so-called mental health diagnoses are spurious.

    Once again, thanks for the contact. It’s very encouraging to hear from someone who hasn’t been taken in by the psychiatric misinformation (-especially a physician!). Keep up the good work.

  • Way

    A few years back I was having a bad time dealing with HIGH anxiety. I was a new mother and wanted to be the best mom I could be. Having frequent panic attacks and afraid to leave my home, I wanted to get help. I went to see my regular doc and he referred me to a psychiatrist. I have always been leary about themespecially after getting put in paxil at 15 and it making me feel like a loon(I did not stay on that crap for long, but I wanted help and motivated by my son I reluctantly went. When I went to her she just sat in this big leather chair and stared at me. I was already nervous and she was a little intimidating to say the least. Finally I spoke and pretty much said that I don’t like being nervous so much, I wish so much didn’t scare me, but I do have good days as well as bad days. No joke maybe five minutes has gone by, that is pretty much all I have said and the first words out of her mouth are “you have bipolar disorder”. Then she writes a scrip for tranquilizers and tells me to come back in two weeks. Even I knew that was nuts. I threw the prescription away and never went went back. I needed real help and she gives me tranquilizers?! So having good days and bad days constitutes a mental illness. What a joke!

  • Phil_Hickey

    Way,

    Thanks for coming in.  The inherent vagueness of the DSM’s so-called diagnoses coupled with the complexity and diversity of human existence have created a situation where almost everybody can attract not just one “diagnosis,” but lots of them.  I’ve heard a great many stories of this sort,
    but your account is truly extreme.

    I once got a referral from Social Services concerning a young woman who had received a “diagnosis” of schizophrenia from a psychologist.  I reviewed the file.  The client seemed to have been competent and cogent all her life.  I phoned the psychologist who made the “diagnosis” and she told me that the woman had scored so high on the MMPI’s schizophrenia scale that she felt she had to give her the diagnosis.  So I made an appointment to see the client.  She was Hispanic.  I had earlier reviewed all the items on the MMPI scale in question, and questioned her about them.  Many of the items involved double negatives.  In English this means a positive, but in Spanish it means a negative.  I’m sure you can see what happened.  When I questioned her on these areas, she frequently answered initially in the “crazy” direction, but when the question was explained, she invariably said, “Oh, no – I mean…” 

    Mental health people are very cavalier with their diagnoses. 

    Thanks again for coming in.

  • Heather

    I have been diagnosed as having everything from Sleep Apnea to being Adult ADD and now as of late Wegeners. Go figure. The number of specialist I have now seen is mind blowing. I have to travel from NC to The Cleveland Clinic every 6 weeks. Here’s the kicker…. because I don’t conform or fit
    in some predetermined guideline NO ONE can figure me out. My last set of test were sent to the Mayo Clinic Research Dept AND they come back with……Wegeners. I’ve had 16 ANCA test in the last 5 months!!! All of them sent to various labs in and out of the US.

  • Heather

    My point is this, mainstream medicine is far to eager to obtain an immediate diagnosis than actually put any time and effort into a patient
    I remember going to see my PCP a few years ago and telling her I am just so exhausted all the time. Her resolution…. an Antidepressant. When I went back begging her to help I was labeled as needy and bipolar! Then it was Mono then ADD and then a Sleep Disorder, when in reality my symptoms were not just in my head… It’s Wegeners. And thanks to the Pharmecutical companies, coming off of some of these antidepressants is Addiction Withdrawl= Hell. Ex: Effexor. What a horrible drug to prescribe knowing it ends up doing more harm than good!

  • Phil_Hickey

    Heather,

    Thanks for coming in. I’m sorry to hear that you have Wegener’s Granulomatosis. This is a truly devastating condition which in its early stages is often misdiagnosed as flu, stress, malingering, etc.. There is a Wegener’s support group at Yahoo which I have found helpful.

    The routine pushing of anti-depressants on people with chronic illness is indeed a national scandal. For the first five years of my illness I was very sick, and at times I was very despondent. I had lost my health, my kidneys, my career, and my quality of life. In my view if I had not been despondent, it would have indicated a serious lack of contact with reality. There was one nephrologist, however, who insisted on pushing me to take an anti-depressant. I refused – with equal insistence. Later I learned that I was the only patient in the clinic who wasn’t taking an anti-depressant!

    By the way, I’m not sure how they are treating your Wegener’s, but in my case I never achieved remission on Cytoxan and prednisone, but I did get remission from rituximab. That was six years ago, and I’ve been in remission ever since.

    Best wishes.

  • Nancy

    I am sorry to read about your problems with Wegener’s; it is a truly terrible disease that I have witnessed firsthand. I am glad you are getting treatment for it.

     I have stumbled onto your blogs just recently and am enjoying your perspective.  I can’t say I agree with you one hundred per cent, but you make some very interesting points.  I would be interested to hear your views on autism (I googled you and autism and didn’t come up with much) and here is my reason:  When my third child was born, I was living in a very small, rural community and a friend of mine had just had her second baby.  We were both new to a community that was not terribly disposed to welcome outsiders so we bonded quite quickly.  I have a nursing background and she had a masters in special education.  After dropping off my first 2 at school, about 3 times a week we would spend the morning together with our newborns, and her toddler would play etc. 

    After her son was 2 weeks old she told me she was very concerned.  Her newborn son was making no eye contact, very quiet, and not engaging at all.  I tried to reassure her with all of the usual platitudes:  “Oh, he’s just placid,” etc., but I could also see that something was not quite right. At 6 weeks there was no smiling, no eye contact, he just existed.   By a year it was very evident that something was extremely wrong.  She was an excellent, engaged mom, and had him in behavioural therapy by 2 years old, her family moved to a major city to get the best treatments/schools for the child, and her husband took a job that paid substantially more but required more travel, just to be able to afford the therapy.

    We are now 18 years later, and my husband occasionally runs into the father in a work capacity.  This child is severely autistic, mostly non verbal, and catatonic at times.  They still have him engaged in multiple behavioural therapies (and I have no idea if he is on medication but I would doubt it).

    My point:  Nothing will convince me that this child was not born this way and that his family interactions had anything to do with it. I saw it firsthand. 

    But, your point is not lost on me.  We were living abroad in South America and my then grade 6 son was lining up to go on a 3 day trip with his school.  There were 2 lines and I got in the longer one thinking it was for the bus.  No.  It was the line up to hand in all the medications for ADHD etc.  I was shocked.  SHOCKED.

    Nature vs. nurture is always an interesting subject and I appreciate your well thought out viewpoint.

  • Phil_Hickey

    Nancy,

    Thanks for your kind words and for your interesting comment.  I struggled unsuccessfully with Wegener’s Granulomatosis for about five year using Cytoxan and prednisone.  Then one of the doctors I see suggested rituximab.  I was skeptical, but agreed to give it a try.  I had four infusions over four weeks.  There were no side effects, and the Wegener’s went into remission and has been in remission since.  That was six years ago.  Of course my kidneys were destroyed, and I’m on dialysis, but I hope to receive a transplant later this year.

    With regards to autism, here are the APA criteria:

    A.  A total of six (or more) items in total from (1), (2) and (3) with at least two items from (1) and one item each from (2) and (3).

    1)  qualitative impairment in social interaction, as manifested by at least two of the following:
    a. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
    b. failure to develop peer relationships appropriate to developmental level
    c. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
    d. lack of social or emotional reciprocity.
    2)  qualitative impairments in communication as manifested by at least one of the following:
    a. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime
    b. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
    c. stereotyped and repetitive use of language or idiosyncratic language
    d. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
    3)  restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
    a. encompassing preoccupation with one or more narrow stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
    b. apparently inflexible adherence to specific, non-functional routines or rituals.
    c. stereotyped and repetitive motor mannerisms
    d. persistent preoccupation with parts of objects
    B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play.

    C. The disturbance is not better accounted for by Retts Syndrome or Childhood Disintegrative Disorder.

     

    Now for me, the most noteworthy feature of this list is that every item is a behavior.  My primary orientation, as you correctly note, is behavioral, and so I tend to look for behavioral explanations.  However, I am not blind to the reality that brains can and do malfunction, and that some of these malfunctions can have a profound effect on behavior.  (For the record, I don’t believe that these malfunctions occur anywhere near as often as the psychiatrists and pharmaceutical companies would have us believe.)

    With regards to the child in question, obviously I can’t say much of a specific nature.  If I were working with this child, however, my first priority would be to conduct an assessment of the situation, including, of course, a very detailed discussion with his mother.  I would also be interested in collateral information from people like yourself, if available.  I would spend a good deal of time observing and attempting to interact with the child.  Out of all this I would be trying to formulate in my head some ideas as to the etiology of the problem as well as some plans for remediation or at least amelioration.

    An often unmentioned but very necessary part of this procedure is an assessment of the credibility of the parent and/or collateral informants.  Now in the case in question it sounds like the credibility of the mother and yourself is extremely high.  I would place a good deal of store in this information, and I would be leaning heavily towards an organic explanation.  This is particularly because you both had noted “something wrong” more or less from birth; you both had had previous babies; you both appear very genuinely concerned for the child’s welfare; and you both have professional experience in the human services field.

    During my working years (I’m now retired) I encountered a great many situations where these conditions did not prevail, and I found myself leaning towards a behavioral explanation.  I have worked, for instance, with mothers who showed little interest in their children’s welfare.  I have worked extensively with mothers who were addicted to alcohol and other drugs, and who routinely subordinated their children’s needs to their own.  I have seen situations where even very young children are plunked in front of a TV set and left there more or less all day long.  And so on.

    I don’t believe that we are born with a drive to socialize.  There may be some very primitive reflexes that facilitate socialization, but most of what we call social interaction is learned or acquired.  And the primary agent for this learning is, of course, an attentive and caring mother figure.  To put it bluntly, the child comes to value people because from day one his food and other comforts are delivered by people.  A child who is neglected or whose physical needs are met in a distant, perfunctory way is likely to place less value on human interaction than a child who is breast-fed and generally cosseted and cuddled.  This, of course, is especially true in the very early months of life.

    So, in my view there are two ways a child might develop the behaviors listed as autistic:  a “broken” brain, or indifferent, disinterested care.

    In cases where there is an organic etiology, I can only speculate as to the nature of this.  It is often assumed that there is a fault in some putative “socializing circuit,” and this may be so.  What I think is more likely, however, is that there would be a fault or deficit in the “pleasure circuit,”  So the child doesn’t derive all that much enjoyment from feeding – and so doesn’t derive much enjoyment from his feeder.  This is largely speculative on my part – I know very little about neurology.

    One of my big complaints with the DSM is that it makes no distinction between different kinds of etiology, when in fact these distinctions are critical to a proper understanding of what’s going on.  Nor is this simply an academic issue.  The response of the treatment community to a mother who has given birth to a child with compromised neural machinery needs to be very different from its response to a mother whose indifference to the child’s welfare has resulted in a marked deficit in social skills.

    We are told nowadays that there is an autism epidemic.  In my view it seems unlikely that an increase in this problem is due to innate neurological factors.  Behavioral factors are more likely.

    One final point – regardless of etiology, efforts to teach the child social skills should always be based on sound principles of behavioral acquisition.

    With regards to South America, I must say that I hadn’t realized that the bio-psychiatric -pharmaceutical web had spread that far, but I suppose I’m not surprised.  They peddle their drugs up here; we peddle our drugs down there!  What a world!

    Best wishes, and thanks again for coming in.

  • mbokil

    I really liked your article. It is one of the reasons I left community mental health practice for private practice with more of a behavioural approach. I found that in the community mental health centres everyone that came in with a little sadness or a loss was pronounced depressed. It was sad how many people just wanted medications. After taking the medications they would wonder why nothing is changing in their life as if the med. was going to radically transform their behaviour. The psychiatrists also handed out Klonopin and sedatives like candy and all the clients with drug problems asked for them and got them. If more people knew what actually went on in these centres they would be appalled.

  • Phil_Hickey

    mbokil,

    Thanks for coming in. It’s always nice to hear from someone “in the trenches.” I agree with what you say. In my view the mental health centers today are little more than drug outlets. There are decent people working there, of course, but they are becoming increasingly disenchanted and many, like yourself, are leaving.

    Of course it could be argued that the centers are simply a reflection of what’s happening in society generally, where psychiatrists have created the pill-for-every-problem philosophy.

    Again, thanks form coming in. Pass the word.

  • ronk thonk

    You are too funny. Not every diagnosis requires a lab test. You do the best you can with the information you have. You all so desperately want to avoid reality, you’d let a kid miss his entire chance at an education because you hate Ritalin. Grow up. Give the kid glasses. Save his life and keep seeking the biological underpinnings.