In recent years, we’ve seen an increasing number of articles and papers from psychiatrists in which they seem to be accepting at least some of the antipsychiatry criticisms, and appear interested in reforms. It is tempting to see this development as an indication of progress, but as in many aspects of life, things aren’t always what they seem.
Last month (June 2015), The Lancet Psychiatry published a paper online in their Personal View series. The paper is titled Childhood: a suitable case for treatment?, and the authors are Ilina Singh and Simon Wessely. Dr. Singh is Professor of Science, Ethics & Society at King’s College London, and is cross-appointed to the Institute of Psychiatry. Dr. Wessely is professor of psychological medicine at the Institute of Psychiatry, King’s College London, and President of the Royal College of Psychiatrists.
The article opens with an abstract:
“We examine the contemporary debate on attention deficit hyperactivity disorder, in which concerns about medicalisation and overuse of drug treatments are paramount. We show medicalisation in attention deficit hyperactivity disorder to be a complex issue that requires systematic research to be properly understood. In particular, we suggest that the debate on this disorder might be more productive and less divisive if longitudinal, evidence-based understanding of the harms and benefits of psychiatric diagnosis and misdiagnosis existed, as well as better access to effective, non-drug treatments. If articulation of the values that should guide clinical practice in child psychiatry is encouraged, this might create greater trust and less division.”
And already there are some red flags. Firstly, the title Childhood: a suitable case for treatment? evokes the kind of concerns often expressed on this side of the issue, that the creation of the “ADHD diagnosis” is essentially a systematic and self-serving pathologization, on the part of psychiatrists, of normal childhood activity.
Also, the term “medicalization” which occurs twice in the quote, is usually used on this side of the debate to indicate the spurious assertion that a non-medical problem (in this case, childhood distractibility/impulsivity) is a disease. But this is not how the term is used by Drs. Singh and Wessely. As becomes evident later in the paper, they clearly endorse the disease assertion, and use the term “medicalization” merely to indicate the assignment of the “diagnosis” to individuals who don’t actually have the “disease”.
The authors discuss biomarkers, and point out that:
“Psychiatry has yet to discover, let alone use, well established biomarkers in diagnosis and treatment…”
But they continue:
“It is also worth considering that biomarkers do not resolve the ethical concern about the diagnosis of ADHD as a violation of childhood: should this particular set of childhood behaviours or capacities be labelled a medical disorder requiring observation or intervention? This aspect of the problem of diagnostic uncertainty in ADHD is not about whether or not the diagnosis is correct; it is more fundamentally about whether or not medical diagnosis is the right thing to do. From this perspective, biomarker evidence might contribute to better (that is, more accurate) diagnosis of ADHD, but clinicians might also get better at doing the wrong thing.”
This is a complicated paragraph, with, I suggest, some muddling of issues.
First, let’s consider the notion of biomarkers. In general medicine, a biomarker is a biological factor that establishes, usually with a high level of confidence, that a particular illness or disease is present. For at least the past five decades, psychiatric research has been preoccupied with discovering the biomarkers for the various “mental illnesses” listed in the DSM. Despite the highly motivated nature of this research, the quest has been a dismal failure.
The central question at stake in this context is: Do the various behaviors used in the DSM to define “attention deficit hyperactivity disorder” constitute an illness? The only way that this question can be answered definitively is to identify a biological pathology, and show that this pathology is present in all the individuals concerned.
At the present time, the “mental illness” known as ADHD is defined by the presence of a certain number of vaguely-defined habitual behaviors from a DSM checklist, and there is no logical reason to believe that the individuals who exhibit the requisite number of habits have any kind of illness. All of the habits in question, even if present to a severe degree, can be adequately understood in fairly ordinary psychosocial terms.
But if it were to be clearly established, through honest, transparent, and replicated research, that the habits in question do, in fact, stem directly from some neurological pathology, then the matter would be resolved, and attention deficit hyperactivity disorder would indeed be a real illness, amenable to investigation, diagnosis, and treatment within the medical model, and it would probably be given a name that reflected the biological pathology rather than the behavioral consequences.
To what extent it would constitute “a violation of childhood” is an interesting, but secondary, issue. Leukemia, spina bifida, meningitis, polio, etc., all violate childhood, but that fact has no bearing on whether or not they can legitimately be considered illnesses.
The authors present a brief composite, anonymized case study. John is an eleven-year-old boy who was assigned a diagnosis of ADHD at age 9 and takes Concerta (methylphenidate) every day.
Then the authors comment:
“Responses to this case presentation are likely to mirror the differences of opinion found among John’s caregivers. Some might argue that John’s childhood represents a life of containment: across different institutional contexts, John’s behaviour is carefully managed, allowing few opportunities for the kind of liberal self-fashioning imagined by Trimble [Steven Trimble, educator, naturalist, and co-author of The Geography of Childhood]. The sociologist Erving Goffman called this process the “bureaucratisation of the spirit”. Others will point out that adult guidance and management are essential to child flourishing; indeed, these form part of society’s obligations of care for a child. Some of this care involves inculcation into social norms through institutions erected for this purpose.”
“Such arguments, which have been the mainstay of the debate over the diagnosis and treatment of ADHD, are unlikely to unlock the stalemate of disagreement.”
And this, to my mind, is misleading. The mainstay of the debate is whether or not the loose collection of vaguely-defined habitual behaviors listed in the DSM constitute an illness. Whether the behaviors in question should be considered problematic or variations on normal is an interesting and important topic. It has probably been the subject of debate since the dawn of civilization, and will likely continue to occupy our descendants for centuries to come, but it is not the “mainstay of the debate over the diagnosis and treatment of ADHD”.
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“If a child’s spirit and freedom are potentially at stake, then we should care about evidence that children such as John are routinely misdiagnosed (that is, diagnosed with non-existent disorders), and we should ask what evidence exists about the consequences of misdiagnosis. So, what are the chances that John has been misdiagnosed?”
Note the confusing reference to “non-existent disorders”, which again sounds like a challenge to the medical status of ADHD, but in fact, as is clear from the context, means only that John doesn’t have the “illness” in question.
The authors address the questions of misdiagnosis and its consequences at some length, but this discussion is entirely within the bounds of mainstream, conventional psychiatry.
“Of course, to reject the possibility that ADHD diagnosis for John might be both valid and beneficial would be a mistake.”
There’s not much ambiguity there.
“But if John has been misdiagnosed (that is, diagnosed with a disorder when no disorder exists), then what can we anticipate for him?”
Drs. Singh and Wessely point out some of the difficulties involved in answering this question:
“No research base yet exists to address the adverse consequences of ADHD nondisease diagnosis. The design of such a study would be a challenge, in view of the ambiguity surrounding ADHD diagnosis.”
In fact, the design of such a study would be more than a challenge; it would be impossible!
ADHD is defined by the presence of a certain number of vaguely-defined habitual behaviors in the DSM checklist. In such a context, the notion that John has ADHD and James doesn’t is meaningless, because each of the vaguely-defined items is open to interpretation and bias, and there is no way to reconcile discrepancies.
If it were discovered that the problems collectively labeled ADHD were in fact caused by an identifiable brain pathology, then the issue becomes moot. Children who have the pathology, have the illness, and those who don’t, don’t. In the absence of such a discovery, any attempts to refine or sharpen the criteria are futile. Absent a clear marker of the so-called illness, attempts to identify and refine diagnosis are simply the perpetuation of error and bias.
And, as the authors themselves have pointed out, no such findings of pathology have been discovered.
But Drs. Singh and Wessely are mired in the traps of psychiatric dogma and complacency.
“For example, most people would agree that in the USA, use of medications to treat ADHD in children is excessive. Fewer people know that the USA has problems of both overdiagnosis and underdiagnosis of ADHD.”
How can they know – how can anyone know – that ADHD is over-diagnosed or under-diagnosed in the US, or anywhere else for that matter, since the criteria, as the authors themselves acknowledge, are inherently ambiguous? If a psychiatrist in Atlanta, Georgia, says that John “often fidgets with or taps hands or feet or squirms in seat” and another psychiatrist in London, England, says no he doesn’t, what fact or argument could settle this matter? How can we say which psychiatrist is over-diagnosing and which is under-diagnosing? How often is “often”? What kind of hand or foot movements constitute a fidget? What kind of movements constitute a squirm? And similar unresolvable ambiguities are inherent in every DSM checklist item.
The DSM checklist purports to be a diagnostic tool. The idea is that if one applies the checklist to children, those who have the “disease” will be so identified, and those who do not have the “disease” will be screened out. But, as the authors of the paper acknowledge, they don’t know the nature or pathology of the disease. So all that they’ve got is the checklist. Tinkering with the checklist items in an effort to improve “diagnostic” accuracy is an exercise in self-deception, because there is no yardstick by which this accuracy can be assessed,
It comes to this: ADHD is a label, arbitrarily and unreliably applied to children who are presenting problems in the classroom, to legitimize drugging them into something resembling manageability and compliance, while at the same time exposing them to the dangers of stimulant drugs. Dressing it up in disease language is a hoax.
. . . . . . . . . . . . . . . .
“We are asking for a more reasoned, less emotional approach to the problem of ADHD diagnosis and medicalisation. To properly investigate the consequences of psychiatric diagnosis and nondisease diagnosis, the impetus to immediately drive a moral stake in the ground must be restrained, to allow intuitions to be weighed against evidence.” [It is clear from the context that the authors are using the unusual term “nondisease diagnosis” to mean: assigning a diagnosis of a disease to a person who doesn’t actually have the disease in question.]
But what kind of evidence can be adduced in this matter? The authors are implying that there is a fundamental distinction between correct diagnosis of ADHD (i.e., cases where the child actually has the “disease”) and incorrect diagnosis (where the child does not have the disease, but is given the label “mistakenly”). Calling for an investigation of the consequences of incorrect diagnosis vs. correct diagnosis is an exercise in futility, because there is no way to distinguish the one from the other, and there never will be unless/until an underlying explanatory brain pathology is identified.
Psychiatry has created and promoted the self-serving fiction that childhood distractibility/impulsivity and various other human problems are illnesses that need to be “treated” with neurotoxic chemicals and other brain-damaging interventions. Suggesting at this very late stage in the proceedings that overuse of the ADHD “diagnosis” may be causing harm, and calling for more research on the “prevalence, causes, and consequences” of this “overdiagnosis” is just another way of endorsing and perpetuating the hoax.
The critical issue here is not that there have been errors of “over-diagnosis”. The critical issue is the spurious medicalization of virtually every conceivable problem of human existence, including childhood distractibility/impulsivity. This was not an error. This was, and still is, the deliberate and self-serving policy of organized psychiatry, financed by pharma, and pursued avidly with disregard for logic, fact, or human integrity.
So why should “the impetus to…drive a moral stake in the ground” be restrained? Psychiatry is the profession that routinely lies to its clients. Psychiatrists tell their clients the blatant falsehood that they have chemical imbalances in their brains, and that they must take the drugs to correct these imbalances. Psychiatry is the profession that allied itself with pharma’s fraudulent research and promotional efforts. Psychiatry as a profession is, I suggest, morally bankrupt, and moral judgments are called for.
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“But the diverse commitments entailed in the broader debate over diagnosis and treatment of this disorder have perpetuated reductive arguments and have scattered energy unproductively. If the goal is to answer the difficult questions that surround ADHD with evidence rather than with speculation, then a more collaborative agenda of research and public engagement is needed.”
Decades of generously-funded and highly-motivated psychiatric research have failed to establish that the habitual behaviors labeled ADHD stem from any kind of neurological pathology. Nevertheless, Drs. Singh and Wessely persist in the notion that ADHD is a disease, and that more research is needed. They call for evidence rather than speculation, while at the same time explicitly endorsing the standard psychiatric position, which is founded entirely on speculation, unsubstantiated assertions, and disregard for the evidence.
“The days when doctors were the sole arbiters of the boundary between normal and pathological states have long disappeared, if those days ever existed at all.”
This is a lofty sentiment, but does not reflect the reality. Psychiatrists, both collectively and individually, do indeed see themselves, and behave, as the sole arbiters of the boundary between normal and pathological, and, at least here in the US, they have five editions of the DSM to prove it.