Archive for category A Behavioral Approach to Mental Disorders
Schizophrenia Is Not an Illness (Part 2)
Posted by Phil in A Behavioral Approach to Mental Disorders on February 21st, 2010
Delusions, contd.
In my last post I pointed out that schizophrenia as defined by DSM is a confusing collection of human problems with no evidence of a common etiology or indeed any valid justification for including them under a common heading. I discussed delusions and made the point that cognitive distortions of this kind are a normal response to failure. When the experience of failure is profound and pervasive, the delusional speech tends to be commensurately extreme. Delusions are not symptomatic of an underlying illness, but rather are a normal human reaction to severe stress or profound failure, particularly in the late teens/early adulthood phase of life. This is the time of life in which our general coping skills are subjected to their first serious tests, and when people experience profound failure at this time, there is a risk that they will drift towards delusional speech. Onset of delusional speech is typically later for women than men, and probably corresponds with the process of giving birth and caring for small children. The potential for strong feelings of failure is high at this point of life also.
Although delusional speech emerges most often in late adolescence and early adulthood, it is obvious that feelings of profound failure can occur at any age and can precipitate delusional speech. In the previous post I listed some of the skills that might be lacking in individuals who fail in this way and the question naturally arises as to why some people develop these skills without apparent effort while others do not. The answers of course are as varied and diverse as human life itself. As parents we try to teach our children how to cope with life and its various vicissitudes, but this ongoing process of teaching doesn’t always go smoothly. Death and other forms of tragedy assail all families at some time, and these experiences can disrupt the normal day-to-day teaching/training of the children. Even in normal times, parents are sometimes overly protective and in particular try to protect their growing children from the experience of failure. But it is only in dealing with the small day-to-day failures of childhood that we learn to cope with major failures later on. Realistic critical self-appraisal is an important component of success in almost all walks of life – indeed in the very business of life itself, but it is only acquired through helping and encouraging the child to reflect constructively on adverse events. The overly protective parent who shelters his/her child from these kinds of situations unwittingly denies him the opportunity to learn from his particular mistakes and to learn how to cope with mistakes generally.
The bio-psychiatric school, of course, claims that the behavior labeled “schizophrenia” is caused by a brain disease, and they vehemently repudiate any attempt to link these behaviors to early family experiences. In my view, the notion that “schizophrenic” behavior is not rooted in childhood learning experience simply flies in the face of common sense and an abundance of evidence (Dozier et al), (Mickelson et al). Most of us as parents do our best to raise our children to be strong, healthy, resourceful adults. But it is naïve to imagine that this desire to do the right thing always translates into actual successful training. There are many obstacles to be overcome. Sometimes we simply don’t know what is the right course of action. Other times we are too busy with work or too engrossed with pressing problems to recognize the child’s need. And tragically, of course, there is the significant number of cases when the child is being blatantly abused at home, bullied at school, or victimized in some other way. Poverty also takes a toll, in that parents who are pre-occupied with financial hardship are often unable to devote as much time and energy to childrearing as they might like.
In short, there are many forces that militate against the child’s acquisition of the skills he/she needs to cope with adult life, and in particular to cope with the experience of failure. Telling parents the palliative falsehood that their child’s delusional speech is the result of a brain disease and has nothing to do with his/her childhood experiences is nothing short of insulting.
Delusional speech arises directly from the experience of failure – from the individual’s misguided attempt to deflect the blame for this failure onto others. And he does this because he has not acquired the skill of accepting and processing the experience of failure in a more rational and productive manner. This kind of speech is then maintained by the attention and various other benefits that it attracts. For instance, in most developed countries it can form the basis for a disability income. In regard to the latter, it is worth noting that people with delusional speech in underdeveloped countries recover much more quickly than is the case in the developed world.
The best way to help a person who habitually speaks delusionally is
- Ignore the delusional speech.
- Pay attention to sensible speech.
- Encourage other instances of cogency and common sense.
- Identify skill deficits. (The list in the previous post would be a good starting point.)
- Teach/coach the needed skills.
- Be patient
- Help the person find some measure of success, initially perhaps in small matters, but as skills develop, in more substantive areas.
- Remember that the skill deficits in question are ones that most of us take for granted (e.g. social interactions) but are extraordinarily taxing for the individuals concerned.
- Remember that delusional speech and “ordinary” speech are on a continuum. There is often a measure of cogency in delusional speech and a measure of nonsense in “ordinary” speech.
The brain is a pattern-seeking machine. It searches for meaning and regularity in the vast array of data presented to it by the senses. When a young person experiences profound failure within a social ethos in which failure is routinely condemned and censured, he has two options. He can acknowledge his skill deficits or he can search for an alternative explanation for the failure. The brain simply needs to make sense of what has happened/is happening and it is a small step to thoughts like “They’re out to get me,” or “I have special status that they don’t understand”, etc..
Next post: Schizophrenia is not an illness, Part 3
Schizophrenia Is Not An Illness (Part 1)
Posted by Phil in A Behavioral Approach to Mental Disorders on January 21st, 2010
The APA defines schizophrenia by the presence of two or more of the following, each present for a significant portion of time during a one-month period:
(1) delusions
(2) hallucinations
(3) disorganized speech
(4) grossly disorganized or catatonic behavior
(5) negative symptoms i.e. affective flattening, alogia or avolition
Signs of the disturbance must have been present for at least six months and there must be significant deficits in one or more areas of functioning such as work, interpersonal relations or self-care.
The “two or more” concept constitutes a substantial flaw in the so-called diagnosis. An individual who is displaying hallucinations and delusions (criteria 1 and 2) will be assigned a diagnosis of schizophrenia. But a person whose behavior is grossly disorganized and whose affect is flat (criteria 4 and 5) can be assigned the same diagnosis. Superficially these presentations are very different, and the only reason for assigning the same diagnosis is that the APA say so. This state of affairs is found throughout DSM. Elliot S. Valenstein, Professor Emeritus of Psychology and Neuroscience at University of Michigan has this to say:
“Although those who directed the DSM-IV project claim that “there has been a stronger emphasis on research data than with previous revisions,” scientific considerations do not play a significant role in the manual. Instead, the psychiatric tradition and sociopolitical considerations seem to have played the major roles in shaping this document. Dr. Allen Frances, who directed the DSM-IV project, stated that “we didn’t want to disrupt clinical practice by eliminating diagnoses in wide use.” Very different symptoms are included under the rubric of “schizophrenia” mainly because they have always been grouped together, rather than because of any new scientific evidence that they share a common etiology.” (Blaming the Brain, 1998, p 161)
This contrasts markedly with general medicine. For instance, there is a disease called Wegener’s granulomatosis which is caused by inflammation of the blood vessels. In the large vessels the inflammation does relatively little harm, but the small vessels can become completely occluded, leading to significant damage in kidneys, lungs, nerve endings, etc.. People with this disease may present very different clinical pictures, but the underlying disease process is essentially the same and the same antibody will be found in their blood stream.
It is widely assumed among the general public that some kind of similar commonality is present in schizophrenia, and that psychiatrists and other mental health professionals are aware of this pathological link. This is simply not the case. Selecting two “symptoms” out of five leads to ten different presentations. Selecting two or more out of five yields 25 different permutations. Whilst one can acknowledge that a measure of overlap and commonality might exist in these various presentations, there is no evidence that all of these people have the same underlying pathology. They are assigned the same diagnosis and deemed to have the same “mental illness,” simply because the APA says so.
The central point of this blog is that the concept of mental illness is essentially spurious, and that the vast majority of the problems set out in DSM are problems of daily living and learned behavior. The so-called diagnoses are routinely presented as explanations of abnormal or unusual behavior, when in fact they are nothing more than labels.
Let’s examine the schizophrenia “symptoms” one by one.
Delusions
A delusion is a false belief. Now the only way you can discern a person’s belief is through his speech, writing, or other overt indication. All of these indicators are behaviors. Speech is behavior, and our patterns of speech are subject to the same behavioral influences as any other behaviors. So when people express nonsensical ideas (or more accurately, when they speak nonsense) we need to ask why. Under the DSM system, we don’t ask why. The delusional speech is simply a “symptom” of the “illness” called schizophrenia, and nothing remains except the prescription of major tranquilizers. In fact, it is widely believed, and promulgated to students, that nothing can be done to ameliorate delusional speech.
The reality is quite different. For decades numerous researchers have demonstrated that delusional speech can be reduced and eliminated through appropriately designed behavioral interventions. Ayllon and Haughton (Modification of symptomatic verbal behavior of mental patients in Behavior Research and Therapy, 1964, 2, 87-97), for instance, achieved a 60% reduction in a hospital patient’s delusional speech by training the staff to ignore these kinds of remarks over a period of 6 months. The individual in question routinely referred to herself as “the Queen,” and would question staff as to why she was not being afforded treatment befitting this exalted position. This had been going on for fourteen years. The staff were trained to simply not respond, to look away, to appear bored, to shift their attention elsewhere, etc., whenever she made these kinds of delusional statements, but to respond normally to non-delusional speech.
The essential point is that delusional speech is behavior and follows the same general principles as any other behavior. In particular, speech which attracts positive attention and approval is more likely to increase in frequency, while speech which attracts no attention or disapproval tends to be eliminated. This is as true of everyday conversations as it is of the delusional speech of mental health clients.
In the same article mentioned above, Ayllon and Haughton describe two mental hospital clients, one with a diagnosis of schizophrenia, the other depression. Both were females and both spent a good deal of time complaining about their health, even though no physical problems had been detected. This had been going on for years. Here again, the hospital staff were trained to ignore the somatic complaints, and to respond positively and attentively to normal speech. The incidence of delusional speech declined rapidly, and by 18 months had been reduced to virtually zero. This research was done 45 years ago! More recent examples can be found at Wilder et al (Journal of Applied Behavior Analysis, 2001, V 34, No 1, 65-68) and Mace and Lalli (Journal of Applied Behavior Analysis, 1991, V 24, No 3, 553-562)
What’s particularly noteworthy here is that mental health staff unwittingly but routinely reinforce delusional speech. Under the DSM system, this kind of behavior is considered a symptom, and the staff tend to “prick up their ears,” so to speak, when clients emit this kind of speech. The staff member may even take notes. Mental health clients are as adroit as anybody else at reading signs of attention and approval, and staff become the unwitting coaches for delusional behavior. This kind of interaction is a direct consequence of the DSM system, under which schizophrenia is conceptualized as an incurable disease, one of whose symptoms is the presence of delusions. If one focuses instead on delusional speech as a dysfunctional behavior which is learned, then the appropriate response becomes clear: ignore the delusional speech and encourage normal speech. Note that this is not the same as trying to talk the individual out of his delusions – trying to persuade him that he is mistaken. These kinds of attempts are generally unsuccessful, because they provide attention and therefore reinforcement.
In Western culture the three great challenges of early adulthood are: emancipation from parents; launching a career; and finding a life partner. At the risk of stating the obvious, some individuals are more successful in these endeavors than others. Most young people, however, manage to stumble through these difficult times and to emerge into adulthood with a reasonable measure of success in these three areas.
Some hapless individuals, however, fail miserably in one or more of these challenges, and a small number of people fail in all three. Whenever we fail – whenever we don’t succeed in meeting an objective – whether the matter is large or small – we always have two options. We can recognize the failure and take corrective action, or we can reorganize our thinking so that the failure gets relabeled as something else. This fundamental truth is expressed nicely in the old adage: A bad carpenter blames his tools. If I decide, for example, to make a window box and the project is a disaster, I can acknowledge that I need to improve my carpentry skills, perhaps even attend some classes, or I can complain that the tools were no good or the lumber was defective, or that my wife is a nag for asking me to do the project in the first place, etc.. In other words, I can change my behavior (in this case my carpentry skills) or I can change my thinking. In general the latter is usually easier than the former.
In the case of the window box, the outcome is relatively trivial. In the case of major failures, however, the outcome is very significant, and the cognitive distortion can be considerable.
Consider the example of a young man who leaves home after graduating from high school, and finds a job in another town. He is filled with hope and a sense of independence, but after a couple of months he is fired. He is so dispirited that he doesn’t seek another job, and a month of two later is evicted from his apartment. Finally, in desperation, he calls “home” and his parents wire him the bus fare and pick him up at the bus station. For good measure, let’s also say that his girl friend has dumped him
Now if he’s an exceptional young man, he might say something like this:
“Thank you mother and father for rescuing me. I really didn’t have the discipline, stamina, or interpersonal skills necessary to succeed in the adult world. If it’s all right with you, I’d like to stay here with you for another year and work on my skill deficits. I’ll get a job and pay you rent, and I’ll join Toastmasters to help me develop some confidence in my dealings with other people, and I would greatly appreciate any feedback or coaching that you could give me.”
Unfortunately a more likely scenario is that he sulks in his room, neglects his personal hygiene, and persuades himself that he would have been ok if people hadn’t had it in for him. In a context of significant failure, these kinds of paranoid thoughts feed on themselves, and in extreme cases reach a level that would be described as delusional. A good measure of family tension usually ensues. Sometimes this degenerates into overt hostility, which further feeds and confirms the young person’s paranoia.
At this stage, he (or she) discovers that delusional speech has a significant pay-off. It reduces expectations. He is no longer expected to find a job, set up home for himself, or find a life partner. He is referred to the mental health system, where he is given a diagnosis and a prescription for a major tranquilizer. He may also be awarded disability status with financial and medical benefits. By this stage the chances of emancipation and functional independence are slim. (The major tranquilizer, of course, dampens down the problem behavior. But real improvements in functioning are rare, and the side effects of the drugs can be truly devastating.) If the parents ask why their son is so paranoid and withdrawn and unmotivated, they will receive the reply: “because he has schizophrenia.” This looks like an explanation, but if the parents were to press the matter and ask: “how do you know he has schizophrenia?” the only possible reply is: “because he is so paranoid, withdrawn, and unmotivated.” The “diagnosis” of schizophrenia is nothing more than a label describing the very behaviors it purports to explain. And a destructive label at that, in that it stifles and suppresses genuine exploration into the true cause(s) of the problem, and genuine remediation of the original skill deficits.
It needs to be stressed that I’m not suggesting that our hypothetical individual is deliberately and consciously faking his “craziness.” It is simply the case that behavior that is reinforced tends to increase in frequency whilst behavior that is not reinforced or which attracts negative consequences becomes less frequent. In the case in question, the behavior of launching out on one’s own, finding a job, and a partner, etc., all ended disastrously. But the behavior of sulking in his room expressing angry paranoid thoughts was rewarded with attention, solicitous concern, home-cooked meals, and an extraordinary measure of power and control over his parents. The outcome is not surprising. An essential point here is that delusional speech and normal speech are on a continuum. People express mildly delusional ideas all the time. Listen to any talk radio show. Listen to politicians railing against their opponents. Listen to religious zealots. Listen to racial stereotypes. Listen to people who insist that the Earth is only 6000 years old. Listen to golfers after they’ve played a bad stroke. Listen to people who get passed over for promotion, etc., etc., etc.. The processes that promote this kind of mildly delusional speech can lead to severe delusions if the conditions are ripe.
It is noteworthy that our young person’s real problem – i.e. a marked lack of general coping skills – never gets addressed. The skills we’re talking about here include:
- critical self-appraisal
- bringing tasks to completion
- not procrastinating
- making good dietary decisions
- managing money; budgeting
- interacting appropriately with supervisors and other authority figures
- interacting with peers; resisting negative peer pressure
- managing a checking account
- getting to bed at a reasonable hour
- “chatting up” prospective sexual/relational partners
- dating
- personal hygiene
- buying and maintaining a car
- house-cleaning and general management of personal space
- choosing friends
- cooking
- good management of time
- etc., etc., etc.
Our culture is generally unsympathetic to individuals who are in trouble because of basic skill deficits. We have helpful programs for vocational skill deficits, but not for the more fundamental skills, such as those listed in the previous paragraph. Individuals with these kinds of deficits are usually subjected to censure and negative labeling (e.g. lazy, dirty, slovenly, prodigal, brash, stupid, klutzy, etc.)
The point here is that the three great challenges: emancipation from parents, launching a career, and finding a life partner – are just that: great challenges. They are not easy. But this fact is seldom acknowledged. The cultural expectation is that young people should be able to do all this without difficulty. And the fact is that most of us do manage to muddle through these years with at least some measure of competency. Others, however, don’t, and some of this latter group crash disastrously and become mental health clients for life. In this regard it is noteworthy that the majority of people who are assigned a “diagnosis” of schizophrenia are “diagnosed” in their late teens and early adulthood – precisely when the basic skills demands are greatest.
Of course the bio-psychiatric school would contend that these individuals were already “sick” before they started their emancipation endeavors – that they had a brain disease which impacted their ability to function effectively. This position may be correct. But the APA’s definition of schizophrenia includes the criterion that “(the disturbance is not due to … a general medical condition.” So delusional behavior that is caused by a brain malfunction is not (by definition) schizophrenia. If indeed it could be established that there are individuals with compromised brains and that this neurological damage was truly the cause of problems in living, then the disease needs to be recognized as such, given an appropriate name (e.g. Smith’s neuropathy or whatever), diagnosed neurologically, and treated appropriately. Meanwhile, assuming a neurological deficit on the basis of unusual or abnormal behavior is intrinsically unsafe. When we are considering people’s behavior, there are always multiple paths to the same place. Consider eleven people on a soccer team playing a game on a Saturday afternoon. They are all engaged in the same activity (playing soccer), but the sequence of events that led them to this point will be extremely diverse. One player, for instance, might be motivated largely by a desire to please his father, while another might be there primarily to annoy his father. A third might be simply trying to lose weight. A fourth is showing off for his girlfriend. A fifth may be trying to dissipate feelings of anxiety and tension, etc., etc., etc..
Similarly, it is clear that genes and physiology have an impact on people’s actions, and it is possible that one person’s delusional speech is the direct result of a brain malfunction. Another person, however, could be emitting very similar behavior without any neurological problem; the delusional speech in the latter case being the outcome of the kind of failure-ridden psychosocial history described earlier. The brain is a pattern-seeking apparatus. It looks for regularities and patterns in the data it receives and stores these patterns for later use. When it can’t discern a pattern (for whatever reason), it makes one up. In the case of our hypothetical young person mentioned above, the correct pattern was his significant lack of skills in a wide range of areas. This is a difficult thing to accept, so his brain invented the notion that other people were out to get him – were sabotaging his efforts. From his point of view this is a perfectly valid explanation for his failures. Of course, it’s not the true reason, and other people see him as paranoid and delusional, and if he is referred to the mental health system, he is given a diagnosis of schizophrenia.
The problem areas which the APA label as schizophrenia constitute an extremely complex topic, and inevitably this blog post has become very lengthy. I have more to say on this matter, but I thought I’d post this and continue with more thoughts on schizophrenia in the next post. Meanwhile, your comments – as always – are welcome.
Next post: Schizophrenia is not an illness (Part 2)
Mental Retardation: A Stigmatizing Label
Posted by Phil in A Behavioral Approach to Mental Disorders on December 6th, 2009
The first diagnostic category in DSM-IV is mental retardation, which embraces those individuals at the lower end of the intelligence spectrum. Intelligence is defined by psychologists as the ability to solve problems, adapt creatively to changing circumstances, and generally manage one’s affairs successfully and functionally. No definition of intelligence can truly do justice to the complexity of the matter, but various standardized tests exist, and within certain philosophical and practical limitations, they all provide reasonably accurate estimates of an individual’s general intellectual ability, as well as identifying areas of particular strength and weakness.
What’s not generally recognized, however, is that the cutoff point for mental retardation is arbitrarily set at the 2½ % ile mark. In other words, if a person’s measured IQ places him or her within the bottom 2½% of the population, then that person is considered retarded. On the other hand, a person scoring barely above this cutoff is considered to be not retarded. The DSM definition of mental retardation also requires that the individual shows some functional impairment in major life areas, but in practice the diagnosis is driven primarily by the IQ scores, which in the hypothetical cases mentioned above are too close to reliably say that one is more intelligent than the other. Nevertheless the former individual comes out of the testing situation with a diagnosis of mental retardation, the latter does not.
The need for a sharply defined cutoff is driven primarily by bureaucratic concerns. The Social Security Administration, for instance, considers mental retardation a disability, and there is an obvious need for clear answers when people apply for disability benefits. In addition, the federal, state, and many local authorities provide funding for services to people in this category, and there is a need for clear answers as to who qualifies and who does not. Schools receive a great deal of additional funding for each child with mental retardation enrolled in their programs, and formal procedures and cutoffs are clearly needed unless another way of conceptualizing these matters and funding these kinds of services is developed.
When the average citizen is asked about mental retardation, he or she generally conjures up a picture of a child or adult with Down’s syndrome or one of the other physical conditions that causes low intelligence (e.g., microcephaly). What’s not generally appreciated, however, is that about fifty percent of individuals who carry this diagnosis have no detectable physical problem or anomaly. This is a direct result of the arbitrariness of the cutoff point. Other things being equal, intelligence is “spread” or distributed through the population. There will be a small number of geniuses (people with very high IQ’s), most of us will lie somewhere in the middle, and there will be a relatively small number of people who are not very bright. This would be the case even if there were no people with Down’s syndrome or other obvious physical conditions that impact this matter.
By diagnosing mental retardation purely on the basis of IQ and functional limitations, we are lumping together two extremely different groups of people: people with clear neurological deficits and people who simply aren’t very bright. The former have something wrong with their brains, the latter do not. Their brains are fine, they are just not as efficient as those of brighter people, in just the same way, for instance, that one person’s lungs, heart, muscles, etc., might work better than another’s.
The practice of labeling these people as “retarded” has a number of important effects, particularly in the area of diminished expectations. Consider a parent being told, “Your child is not very bright. In fact, in an average group of a hundred children, he would come pretty close to last in intellectual matters. There is nothing wrong with him, as such, it’s just the way he is, in the same way, for instance, that another child might be very short, etc..” Contrast this to, “Your child is retarded,” which is what this parent would be told under the present DSM system of diagnosis, labeling, and categorization. Quite apart from the unpalatability of the message, there is an almost inevitable tendency on the part of the parent to diminish expectations and to assume the child will be incapable of learning various material, much of which is, in fact, well within his or her potential. A great deal has been learned over the past fifty years concerning the negative effects of this kind of stigmatizing labeling, but this body of research is routinely ignored by those who promote and maintain the DSM categorization system.
These kinds of diminished expectations occur also in the classroom. When a teacher has been told that a particular child is retarded, he/she is more likely to accept a lower standard of work from that child than would have been the case had the “retarded” label not been applied.
Another problem with the “diagnosis “ of mental retardation is that it promotes the notion that the problem lies exclusively within the individual – a lack of “intellect.” This kind of thinking goes back to pre-scientific speculation about human activity. Today we know that there is no such thing as intellect. Rather there is behavior which is more or less adaptive – more or less intelligent. And we also know that behavior is always the result of an endlessly dynamic interaction between an individual and his/her environment. The fact is that some home environments are more fostering of intelligent behavior than others, and it is likely that many children currently labeled “mildly retarded” could be helped significantly in this area with some focus of attention on the home environment. The “diagnosis” of “retarded,” however, militates against this kind of intervention, in that the deficiency is presumed to lie within the child rather than in the child’s environment. Because the “diagnosis” appears to be an explanation of the poor performance, it stifles genuine exploration into the true nature of the problem.
Even with regards to the individuals who do have a physical etiology, similar observations apply, and in general mental retardation programs in recent decades have discovered that there is a great deal of untapped potential in their clients, much of which had been obscured in the past by the stigmatizing effects of the label.
Public attitudes towards people of low intelligence have softened markedly in recent decades, probably largely as a result of deinstitutionalization, and the fact that these individuals are routinely obtaining gainful employment in fast food restaurants, grocery stores, and other locations. In many areas despite the DSM label, mental retardation programs have tackled the problems of their clients creatively and energetically, and in many respects have managed to overcome some of the stigma and other negative consequences of the diagnosis.
In the 50’s and 60’s the term “retarded” gradually replaced the earlier technical terms, which were moron, imbecile, and idiot, and at the time represented a clear improvement. “Retardate,” however, has now become a term of disparagement, especially among school children, and the time for terminology update seems overdue.
Because the concept of retardation has been widely accepted in our society, there is a tendency to see it as an explanation for an individual’s low level of functioning. When a teacher, for instance, asks, “Why is Johnny so slow? Why can’t he learn this stuff?” the school psychologist replies, “Because he’s retarded. His IQ is only 65.” Like most mental disorder diagnoses, this looks like an explanation and is generally accepted as such by parents, teachers, and other concerned professionals. Nothing, however, could be further from the truth. The label “retarded” explains nothing. It just means that Johnny scored below a certain cutoff on a test. In other words, he’s not low-functioning because he’s retarded, but rather he’s called retarded because his level of functioning (as measured by this test) is low. This is a very important distinction, because the diagnosis of mental retardation provides the impression that the matter has been explained, and often removes the incentive for any further in-depth investigation or exploration of the individual’s problem. Despite the gains in recent decades, retardation is still widely regarded as an irremediable condition, and the label still carries heavy overtones of hopelessness and diminished expectations.
Adjustment Disorder: Everyone can have a mental illness
Posted by Phil in A Behavioral Approach to Mental Disorders on October 15th, 2009
According to the DSM, the essential feature of this mental disorder is “…the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors.” The manual defines clinically significant as either:
“marked distress that is in excess of what would be expected given the nature of the stressor”
or
“significant impairment in social or occupational functioning.”
DSM provides a number of examples of the kinds of stressors that might precipitate a diagnosis of Adjustment Disorder. These include:
- termination of a romantic relationship
- marked business difficulties
- marital problems
- seasonal business crisis
- living in a crime-ridden neighborhood
- natural disaster
- starting school
- leaving one‘s parents’ home
- getting married
- becoming a parent
- failing to attain occupational goals
- retirement
- a chronic disabling medical condition
- financial difficulties resulting from a divorce
And these are just some examples. In other words, if you encounter any of life’s difficulties, and your response to this difficulty is excessive, as defined by a mental health worker, then you have a mental disorder.
There are six sub-types of this so-called mental disorder:
Adjustment Disorder:
- with anxiety
- with mixed anxiety and depression
- with disturbance of conduct
- with mixed disturbance of emotions and conduct
- and, of course, unspecified
It’s an obvious fact that life from time to time presents difficulties, some minor, some major. It’s also an obvious fact that sometimes we deal with these difficulties fairly effectively; other times less so. But who is to decide whether our reaction to the difficulty was “excessive”? Some people respond to crises in a stoical, confined way; others are very emotional. There is no yardstick for how effectively people cope with stressful situations. Nevertheless, the APA has invented this mental disorder as a way of broadening their psychiatric net to embrace as wide a client base as possible. And because of the vagueness of the criteria, anybody experiencing a stressful situation can be assigned this diagnosis. And because no distinction is made in practice between the terms “mental disorder” and “mental illness,” these individuals are deemed to have a mental illness and are routinely prescribed drugs.
So the person who has lost his/her job and is feeling down; the family whose house was destroyed by fire or tornado; people caught up in a hurricane, flood, or other natural disaster – all of these people are eligible for a diagnosis. Even less dramatic stressors can serve as portals to Adjustment Disorder. Working in a hostile environment, an unhappy marriage, or problems with neighbors would all qualify an individual for a diagnosis of Adjustment Disorder, provided only that his/her reaction to the particular stressor was “in excess of what would be expected.” And of course, it will be decided by a psychiatrist or other mental health worker whether the response is excessive. In practice if you go to a mental health clinic and tell them that there’s a lot of tension at your place of work and that the worry is keeping you awake at night, you will almost certainly receive a diagnosis of Adjustment Disorder, you will be enrolled in the ranks of the mentally ill, you will swell the statistics cited in earlier blogs, and you will be given a prescription for a sleeping drug (and possibly some free samples).
The primary theme of this website is that the medicalization of all human problems, which has progressed steadily for the past 40 years, is a spurious and counter-productive activity, and is promoted for the benefit of psychiatrists and pharmaceutical companies. Adjustment Disorder is perhaps the most glaring example of this activity, in that it widens the psychiatric net to every conceivable facet of human life. Any problem whatsoever renders an individual eligible for a diagnosis. So when a former Surgeon General stated that a fifth of all Americans will experience a mental disorder in any given year and that fully half of the population will have a mental disorder at some time in their lives, he was including in these statistics vast numbers of people who simply were experiencing an ordinary problem of daily living.
If individuals going to a mental health center with problems of this kind received some genuine support and guidance, the “diagnosis” might have some justification as a portal to this kind of assistance. What happens instead, however, is that the individual is given a prescription for an anti-depressive or anti-anxiety drug and is encouraged to “keep coming back” for future appointments. Additional “diagnoses” are often “uncovered” during this process, and the individual becomes a client for life.
Facing and overcoming difficulties is an integral part of human existence. I’m not suggesting that life should be one long arduous uphill struggle. But the notion that we can wave away our difficulties by calling them mental “illnesses” and taking drugs is a destructive and stigmatizing philosophy which undermines the value of human life. Psychiatry’s message to mankind, embodied in the DSM, embraced wholeheartedly by mental health workers everywhere, and endorsed by the pharmaceutical companies, is
“You can’t cope without our pills.”
The message is that as a species we no longer have to strive to overcome life’s vicissitudes. Just take a pill. To see psychiatrists and pharmaceutical companies promoting this philosophy is somewhat understandable. After all, they are businesses and their primary interest lies in the area of expansion and profits. To see politicians promoting such spurious and destructive concepts, however, is scandalous.
Next Post: Mental Retardation: A Stigmatizing Label
Bipolar Disorder Is Not An Illness
Posted by Phil in A Behavioral Approach to Mental Disorders on September 6th, 2009
DSM’s criteria for a manic episode are given below:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a Mixed Episode
D. The mood disturbance is sufficiently severe to cause marked impairment in
occupational functioning or in usual social activities or relationships with others, or
to necessitate hospitalization to prevent harm to self or others, or there are psychotic
features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication, or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count
toward a diagnosis of Bipolar I Disorder.
The manic episode is an important part of the DSM system because it acts as the basis for a diagnosis of Bipolar Disorder. DSM lists several variations of Bipolar Disorder, each with its own specific criteria, but in general, if a person has had a manic or hypomanic episode, he has bipolar disorder.
Let’s take a look at criterion A. This criterion calls for a distinct period of abnormally and persistently elevated expansive or irritable mood, lasting at least a week… The DSM defines elevated mood as: an exaggerated feeling of well-being or euphoria or elation. Expansive mood is defined as a lack of restraint in expressing one’s feelings, frequently with an over-evaluation of one’s significance or importance. Finally irritable mood is defined as being easily annoyed and provoked to anger.
So the very basis for a diagnosis of Bipolar Disorder is either feeling particularly good about everything or feeling particularly grumpy and angry. How can the same illness manifest itself in such completely different ways? And bear in mind that these are not relatively trivial, incidental aspects of the so-called illness. These are the defining features. The very essence of bipolar disorder – according to DSM – is an episode of profound happiness or an episode of profound grumpiness and irritability. This is indeed a strange illness.
But let’s move on to criterion B. This provides a list of seven specific “symptoms,” three of which must be present for a positive diagnosis. (Incidentally, if the mood problem in criterion A is “only irritable,” then four items are needed from the list.)
This practice of providing a list of symptoms and specifying how many must be present in order to provide a diagnosis is very common in DSM and raises obvious difficulties. First is the arbitrariness of the number chosen. Why three? Why not two or four? The answer, of course, is because the APA says so. The second objection is that different groupings of three will generate very different presentations. For instance, a person meeting criteria 1, 3 and 4 will be grandiose, overly talkative, and somewhat scattered in his choice of topics. Whereas a person who meets criteria 2, 5, and 7 will be sleeping very little, very distractible, and will be maxing out his credit cards in unrestrained buying sprees. The notion that these two presentations are in fact manifestations of the same illness is untenable. This is particularly so in that the only justification for this position is that the APA say so.
A more important difficulty stems from the question: Why should these problems be considered indications of illness? Let’s look at each of the so-called symptoms in turn.
1. inflated self-esteem or grandiosity.
In this context it is worth noting that one of the “symptoms” of a major depressive episode is “feelings of worthlessness…” So if you haven’t got enough self-esteem, you’re depressed, but if you have too much, you’re manic. This raises the question: how much self-esteem is OK, and how much (or how little) is pathological? Who decides? In practice, of course, intake workers at mental health centers and hospitals make the decision, and the decision-making is intrinsically subjective and unreliable. In an informal way, we have all encountered individuals who are “full of themselves” to an obnoxious degree. Intuitively we attribute this kind of behavior either to an attempt to mask a marked sense of inferiority or to poor socialization training during childhood. The notion that this character trait is really a symptom of an illness is an extreme position for which the APA offers no proof. Indeed there isn’t even an argument. The APA simply says so.
2. decreased need for sleep…
This is a complex subject. A great deal has been learned about sleep but much remains unknown. Sleeplessness might well be an indication of some neurological damage or illness, but might on the other hand be simply a reflection of individual differences. There are numerous reports in history of prominent individuals who managed perfectly well on four or five hours sleep each night. Others need eight or nine. It would require a neurological examination to determine if a particular sleep pattern were pathological or a variation of normal. But even if a pathological condition were established, this would indicate a neurological condition, not a so-called mental illness. It is also worth noting that a “decreased need for sleep” very often is nothing more than excessive intake of caffeine or other stimulant drugs.
3. more talkative than usual or pressure to keep talking
We’ve all encountered individuals who talk too much – who hog the conversation. This phenomenon is best conceptualized as rudeness, i.e. a disregard for the normal conventions that direct social intercourse. This particular form of rudeness is usually the result of poor training during childhood. Small children sometimes talk excessively and try to dominate social relationships in this way. If steps are not taken to train them towards a more give-and-take approach to conversation, they often carry this trait into adult life.
4. flight of ideas or subjective experience that thoughts are racing
DSM defines flight of ideas as: “A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When severe, speech may be disorganized and incoherent.”
It’s clear from this definition that the real issue here is not so much flight of ideas as flight of speech. Most people in fact experience flight of ideas on a fairly regular basis. It’s called stream of consciousness, and it flows like a babbling brook, swishing and eddying around twists and turns, over rocks and sand banks, endlessly changing and shifting. Even as I write these words, for instance, my thoughts have flitted to actual streams and rivers I have known. The problem is not that the person experiences a bewildering array of successive ideas, but rather that he puts these ideas into words. Most of us learn to censor stream of consciousness material at an early age and to confine our speech to items that have meaning and relevance for our listeners. A small number of poets and song-writers have managed to make a good living by dispensing with this kind of censorship, but most of us confine our verbal utterances to those ideas that have cogency and relevance for others. We call it discipline or self-control. Once again, it is lacking in small children whose early speech does indeed reflect stream of consciousness material. Proud parents are usually delighted with this initially, because it represents a major developmental breakthrough. Most parents, however, fairly soon begin the process of training and coaching that results in what we would call normal speech. If this training does not occur or is thwarted or frustrated for whatever reason, then the individual grows up without acquiring this skill. As with many skills normally acquired in childhood, it can be extremely difficult to learn in later life.
This facet of the manic presentation then is best conceptualized as a deficit in training and socialization, rather than a symptom of a medical condition.
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
This is essentially the same thing as the flight of ideas discussed above. The effect of splitting this phenomenon into two separate “symptoms” is to increase the likelihood of a positive “diagnosis.” Remember, it takes three (or more) symptoms for a diagnosis. If a person displays flight of ideas, he will almost certainly also meet the criteria for distractibility. So you get two hits for the price of one. The primary purpose of DSM is to generate business for psychiatrists.
6. increase in goal-directed activity (either socially, at work, or school, or sexually )or
psychomotor agitation.
Most people would probably see an increase in goal-directed activity as a good thing. Painting the garage or mowing the yard is better than vegetating in front of the television. But this is not quite what the APA has in mind by “goal-directed activity.” Elsewhere in the text they describe goal-directed activity that is “excessive” and as examples they mention: “ taking on multiple new business ventures…without regard for the apparent risks…,” “…calling friends or even strangers at all hours of the day or night…;”
“…writing a torrent of letters on many different topics to friends, public figures, or the media.”
It is clear that the real issue here is not goal-directed activity as such but rather irresponsible and inconsiderate activity. Once again, responsibility and consideration for others are attributes that we acquire during childhood through the normal methods of parental discipline, coaching, role modeling, etc.. When we see a person displaying a marked deficit in these areas the most parsimonious assumption is that his/her training and discipline in these areas was for some reason neglected or deficient. The notion that the person is ill is certainly not obvious. The APA offers no proof or even arguments for this position.
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
Once again, what’s involved here is what most people would call irresponsibility: the kind of behavior we try to discourage in our children through the normal time-honored methods of discipline and example. The notion that these kinds of irresponsible and self-indulgent behaviors are in fact caused by a diagnosable illness is quite a reach. Bipolar disorder, like most of the other DSM diagnoses, is not something a person has, but is rather something that a person does. It is constantly presented by the APA, and by practitioners in the field, however, as something a person has (like diabetes) and something that is best treated with drugs.
The fact that lithium has a calming affect on individuals who behave in this manner is often cited as proof that the behavior in question really does stem from an illness. The logic is untenable. A couple of beers can be very effective in helping shy people overcome their inhibitions. Very few rational people would conclude from this that shyness is an illness and alcohol a “medication.” In addition, lithium has a calming effect on all people – not just those who carry a diagnosis of bipolar disorder.
Lithium carbonate is a salt – found widely in nature – and until 1949 was sold openly in the United States as a substitute for table salt. Besides having a salty taste, lithium salt has a calming effect on people’s behavior. With regards to the latter, the mechanism of action is unknown. There have been numerous proposed theories, but none has produced conclusive evidence or gathered much support.
In some respects the shyness/alcohol analogy mentioned earlier is even more apt. The chronically shy person can acknowledge his problem and take corrective action using the normal time-honored methods of effecting personal change. Or he can simply drink a couple of beers before every social situation. Either solution to the problem will work. Similarly the manically irresponsible person can acknowledge his problem behaviors and tackle them in the normal way – or he can take lithium carbonate. The latter is often quite effective in dampening the behavioral excesses, but like the alcohol, it also has some long-term side effects.
The central point of this and my earlier posts is that there are no mental illnesses. There are problems of living – problems that human beings encounter, sometimes resolve, sometimes live with. The so-called mental illnesses are an attempt to explain or understand these phenomena, but as explanations they are spurious, unhelpful, and indeed, counter-productive. They are merely labels.
A perfect analogy to the mental illness explanation of human problems is the phlogiston explanation of fire or the witchcraft theories of illness and crop destruction. The popularity of a concept is often independent of its validity. The phlogiston theory of fire is a good example. This theory, which held sway among scientists during the 1600’s and most of the 1700’s, maintained that combustible objects contain an element called phlogiston which was released when the object was burned. Non-flammable objects simply didn’t have this substance. Towards the end of the 1700’s evidence was gradually amassed to debunk the theory in favor of the oxygen-combination ideas of today. Many scientists, however, including Joseph Priestley (the discoverer of oxygen!), tried to cling to the older theory. Similarly, in former years, sickness and crop failures were often attributed to witchcraft. Here again, we have a spurious theory, i.e. that sickness and crop failures are caused by the actions of these so-called witches. Such thinking – back in the days – was very widespread, and witch-burnings were popular events. But the concept was nonsense, and today, thanks to science, we have a better understanding of the causes of illnesses and crop failures. Popularity is a very unreliable barometer for conceptual validity. Phlogiston doesn’t exist. There’s no such thing as witchcraft. And there are no mental illnesses. Fire, however, does exist. Crop failures and illness are realities. And human problems of living are real. People are complex and diverse and the problems we encounter on our journey through life are also complex and diverse. Some of the problems we meet are relatively minor and easy to deal with. Others can be truly overwhelming. Some are indeed medical problems and require medical help. Others do not.
The so-called mental illnesses are problems that do not require medical help. The medicalization of all human problems of living is as spurious as the phlogiston and witchcraft theories mentioned earlier. It is also counter-productive. Drugs are not an effective solution to life’s problems any more than the burning of so-called witches was a solution to crop failures or illness.
The medicalization of all human problems is about turf. The American Psychiatric Association is the psychiatrists’ trade union, and has as its primary agenda the promotion of its members’ interests. There’s nothing intrinsically wrong with this – all trade associations do the same. That’s why they exist. The problem with the APA, however, is that they have been so successful. At the present time one would be hard pressed to identify any problem of human living that is not covered by a DSM “diagnosis.” The purpose of these diagnoses is to legitimize psychiatric intervention and the prescription of drugs in any and every human problem.
At the risk of repetition, I am not saying that people should not use drugs. It is not for me to tell people what they should or should not ingest. These are decisions that people have to make for themselves. What I do object to, though, are the spurious notions that these pharmaceutical products are medicines, and that they are being prescribed to combat illnesses.
Next Post: Adjustment Disorder: Everyone can have a mental illness
Depression Is Not An Illness
Posted by Phil in A Behavioral Approach to Mental Disorders on July 28th, 2009
Contrary to the APA’s assertion, depression is not an illness. In fact, depression is an adaptive mechanism which has served the species well for millions of years. When things are going well in our lives, we feel good. This good feeling is nature’s way of telling us to keep doing what we’re doing. When our lives are not going well, we feel down or depressed. This is nature’s way of telling us to make some changes.
This is very similar to pain. Pain is a signal that tissue is being damaged and that urgent action is needed. For instance, if you touch a hot stove, the pain induces an immediate reaction to pull your hand away. Usually this is accomplished with minimal damage to the skin. Without pain, we would not respond as quickly to these kinds of situations, and we would incur a great deal more tissue damage than is actually the case.
Depression or despondency is not as acute a sensation as pain. It is more generalized and it signals – not imminent tissue damage – but problems of a more general nature. In order to feel good, the following six factors must be present in our lives.
- good nutrition
- fresh air
- sunshine
- physical activity
- purposeful activity
- good relationships
When any of these factors are missing, or are present to only a slight degree, we begin to feel despondent or depressed. When many of these factors are missing to a large degree, we sink into despair. Over the years, I have worked with hundreds of people who were depressed. To all of these people – without exception – I could say, “If I were in your shoes, living the life you are living, I would be depressed too.”
Many of these individuals lived on a diet of soda pop, cigarettes, and salami sandwiches. Others drank enormous quantities of alcohol. Few ate vegetables regularly. Many stayed indoors almost all the time. Physical activity was almost always minimal. Purposeful activity – i.e. activity directed towards some kind of goal – was seldom present, and good honest, open relationships almost non-existent.
The point here is not to disparage or castigate people who are depressed, but rather to point out that depression is essentially and fundamentally a function of what we are doing – how we are living our lives. It is not an illness. It is the body’s natural feedback system. It is nature’s way of trying to induce in us some motivation to make changes in our lifestyle – to eat better; to abstain from toxic substances; to get out in the fresh air and sunshine; to identify goals and pursue them and to talk to friends and family honestly and openly about the things that trouble us. If we do these things consistently and regularly – if we integrate these things into our daily routines, then we will start to feel good. If we don’t do these things, we will feel depressed. Or as Peter Breggin, MD, puts it in Antidepressants Cause Suicide and Violence in Soldiers: “The principles for overcoming depression are exactly the same principles required for living a good and happy life.”
Everybody experiences an occasional down day. But we also know what to do about it – get out for a walk; start a project; talk to a friend or loved one, etc. Chronically depressed people, however, are individuals who have been neglecting these areas for years. They spend the vast majority of their lives indoors, watching television and eating snack food. They are often over-weight, have no goals other than the next TV show, and although they may have many acquaintances, they do not share their concerns and worries in an open and honest manner.
Of course, not all depressed people are deficient in all these areas. Some depressed people eat well, but never share their worries or concerns with anybody. Others share their worries, but have no purposeful activities. Others have purposeful and rewarding jobs, but never get outdoors and never engage in physical activity and so on.
To feel consistently good, we need to have all of these factors present in our lives to a substantial and significant degree. Nor is this such a daunting proposition. A person who eats moderately from the five main food groups; who controls his intake of sugar and alcohol; who doesn’t smoke; who has a job or hobby that provides challenges and a sense of fulfillment; who gets outdoors most days for exercise or even for a brisk walk; and who has at least one other person with whom he is open and honest, will feel generally positive. A person whose life is lacking in one or more of these areas will feel generally negative. This latter is not an illness – it is not an instance of something going wrong in our bodies. Rather it is an instance of something going right. Depression is a message from the organism calling for change. Induction of negative feelings is the only language the organism has to express the need to make changes.
Severe losses can, of course, precipitate depression even in otherwise very orderly and functional lives. Even when all six factors are present to a substantial degree, the loss of a loved one will usually result in profound feelings of depression. Similarly, the loss of one’s career, health, home, etc., will generate some measure of depression regardless of previous lifestyle. People who have been living functional and productive lifestyles, as described above, however, will normally come to terms with the loss in a reasonable time frame. They will talk about the loss to the people in whom they confide; they will continue to eat well and to exercise, and will continue with the various purposeful activities they have always pursued. Gradually the sense of loss will recede and the ability to enjoy life will return. When it seems as if life is coming apart at the seams, it is our routines that save us – provided we have established good functional routines which incorporate the six factors mentioned above.
However, for people whose lifestyles are deficient, or only marginal, in terms of the six factors mentioned earlier, a major loss can put them “over the edge,” and they sink into a state of chronic long-term despondency. In this regard it is worth noting that all human lives are, sooner or later, touched by major tragic losses. What matters is: how equipped are we, in habits and lifestyle, to handle these losses. When a person goes to a mental health center and asks for help with depression, the first priority should be a detailed assessment of the person’s lifestyle, habits, relationships, history, etc., to determine the source of the depressive feelings. From this assessment, a remedial program should be developed and active support and assistance provided to the client in the implementation of this program.
In practice this almost never happens. The client who mentions depression is routinely shuffled off to the psychiatrist. He gets a prescription for an antidepressant and is told (falsely) that his depression is an illness like diabetes, and that he must take his pills in the same way that a diabetic must take insulin. If supportive or adjunctive therapy is provided at all, it usually takes the form of patronizing pats on the back or reminders to take the “medication.”
Despite decades of highly motivated research on the part of pharmaceutical companies and university departments funded by pharmaceutical companies, no evidence has ever been presented that depression is caused by a physical problem in the brain. Yet this assertion is routinely presented to clients and their families as justification for the drug prescription. Elliot Valenstein, Professor Emeritus of Psychology and Neuroscience at the University of Michigan, having reviewed the various biological theories of depression, summarizes the results as follows in his book Blaming the Brain:
Although the often-repeated statement that antidepressants work by correcting the biochemical deficiency that is the cause of depression may be an effective promotional tack, it cannot be justified by the evidence.
The fact is that anti-depressants are mood-altering drugs (essentially in the same general category as alcohol, cocaine, amphetamines, etc.). All of these drugs have in common that they alter people’s moods. They make people feel better. That’s why people take them! But it doesn’t mean they are a good idea. There are two ways to get drugs in the United States. You can go to the street corner and buy them illegally; or you can go to a physician and tell him you are depressed, or anxious, or both. Either way, you’ll get something that will give you a temporary “fix” for whatever negative feelings are troubling you. But you will not get any real help with your problem.
In recent years many hospital and clinics have been offering free depression screenings. If you go in for one of these screenings, it’s obvious that you have been experiencing some depression, and the interviewer will quickly establish (through insultingly simplistic questionnaires) that, yes, you are indeed depressed, and that you would benefit from one of the many wonderful antidepressants currently available and wouldn’t you like an appointment to see our psychiatrist. These “free” screenings are almost invariably paid for by a pharmaceutical company. They are a form of marketing and have been a major factor in the promotion of psychotropic drugs. The hospital staff who participate in these charades are well-intentioned, but in fact are mere cogs in an enormous drug-marketing scheme.
The purpose of the DSM is to promote the false notion that depression is really an illness, and to legitimize the prescription of mood-altering drugs. The manual lists several different kinds of depression. Acute, severe depression is called Major Depressive Disorder. Persistent though less severe depression is called Dysthymia. Depression that comes and goes and is interspersed with periods of mild mania is called Cyclothymic Disorder. And so on. And, of course, if a client doesn’t meet the criteria for any of these – there’s always Depressive Disorder Not Otherwise Specified: a residual category to broaden the scope of the diagnostic net. In fairness to the APA, all of the several diagnoses require a fairly significant level of severity. In practice, however, the precise criteria are routinely ignored. In fact, most of the staff working in the mental health system have only a vague notion of the criteria. A client who says he’s depressed is assigned a diagnosis and is given anti-depressant drugs.
There are, of course, small numbers of mental health staff who although constrained by regulatory agencies to work within the DSM context, nevertheless ignore the implications of the sickness model and provide real help to their clients. These staff members are a very small minority and the vast majority of mental health workers embrace the DSM taxonomy wholeheartedly and believe unquestioningly in the ontological validity of the diagnostic categories.
Next Post: Bipolar Disorder
Posttraumatic Stress Disorder
Posted by Phil in A Behavioral Approach to Mental Disorders on June 23rd, 2009
One of the anxiety disorders listed in DSM is posttraumatic stress disorder. The criteria for this condition are listed below:
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person’s response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior
B. The traumatic event is persistently reexperiencd in one (or more) of the following:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) , as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g. unable to have loving feelings)
(7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Posttraumatic stress disorder consists essentially of painful memories. Even the most organized and insulated lives are touched by tragedy and misfortune. Painful memories are an integral part of the human condition. Occasionally individuals are involved in incidents that are truly horrific, and the memories associated with these events are commensurately painful. The paradigm example of this is warfare, but traffic accidents, criminal attacks, and natural disasters are all potential sources of painful memories. The APA’s use of the term “…a threat to the physical integrity of self or others” (in A: above) is sufficiently vague to embrace almost any kind of traumatic event.
Everyone is familiar with painful memories and everyone is also familiar with the fact that these memories can and do intrude in our present lives. People who have lived through severe flooding, for instance, tend to react negatively to even light rainfall for years afterwards. People returned from combat sometimes react strongly to loud noises. What has happened in these cases is that the bad memory has in itself become a source of fear or anxiety, even though it poses no actual threat. The fear response, which initially was triggered by the traumatic incident, is now triggered by the memory of the incident. In other words, the person is literally afraid of his own thoughts.
Painful memories are not trivial. They can be extremely difficult to deal with and can interfere with present functioning. But they are not illnesses. Memory is an adaptive device – it helps us to survive and to cope with our surroundings. But memory doesn’t screen out unpleasant material. In fact, memories of particularly unpleasant incidents tend to stay with us longer, because of the emotional significance we attach to them at the time.
It is an obvious fact that our experiencing of the world around us modifies structures within the brain. If we hear a catchy tune a few times on the radio, we find that we can sing the melody without difficulty. Clearly there is some “trace” of the tune inside the brain that wasn’t there before. Similarly it has been shown in several animal studies that repeated exposure to stressful situations can produce long-lasting structural and functional changes in the brain. These studies are often cited as proof that PTSD really exists and that it is a brain disease. The reasoning, however, is muddled. Even if we concede that repeated exposure to stressful events can damage the brain and cause the individual to behave in erratic and destructive ways, this does not prove that all of the people who behave in erratic and destructive ways have damaged brains. The critical point is this: If indeed there is a neurological condition which is brought on by repeated exposure to stress and which in turn causes the individual to behave in an erratic and destructive manner, then this condition needs to be identified as a neurological illness, given an appropriate neurological name (e.g. hypersensitive dopamine receptors), and should be treated by neurologists. Some of the people currently diagnosed with PTSD would likely meet the criteria for the neurological illness, but just as likely, many would not. In particular, the diagnosis of this neurological illness would not rest on criteria that are purely behavioral.
Posttraumatic stress disorder as it is defined in the DSM is not an illness. There is nothing going wrong in the individual’s body; no diseased organs; no dysfunctional processes; no confirmed neural pathology – nothing that a normal intelligent person would consider necessary for a condition to be called an illness.
A particularly interesting feature of this matter is that people have been dealing with painful memories (and helping others deal with them) since the beginning of time. The “secret” to desensitizing this kind of material is to talk about it. In our culture women are better in this regard than men. If a woman is involved in a traumatic incident, she usually recounts the matter many times – to her mother, her sister, her husband, her best friend, her hairdresser, etc. With each telling, the memory loses some of its potential to hurt. A man, on the other hand, in the same situation, will often feel that talking about the incident constitutes childish whining, and he keeps it to himself – shuts the memory away – where it remains strong and potent.
An individual who goes to a mental health center for help with painful memories is routinely assigned a diagnosis of posttraumatic stress disorder. He will be prescribed an anti-anxiety drug to keep him becalmed and he will talk to a counselor. He will tell the counselor about the traumatic incident and might be assigned to a PTSD “survivors’ group”. At subsequent group meetings he will be encouraged to tell how he is doing in his day-to-day matters, and he will listen to each newcomer recount his/her precipitating trauma.
The talking and the listening, of course, are helpful, though the benefits are mitigated somewhat by the fact that he is under the influence of the prescription drug. But what’s really needed – repetitive recounting of the incident – doesn’t occur.
In addition, PTSD is a major gateway diagnosis, and diagnoses of depression and bipolar disorder are often tacked on for good measure – or to extract more money from insurance companies.
Next Post: Depression is Not An Illness
Anxiety Disorders
Posted by Phil in A Behavioral Approach to Mental Disorders on May 7th, 2009
Fear is the normal human response to imminent danger. It is an adaptive response, in that it is helpful to survival, and it occurs in almost all animal species. When our cave-dwelling ancestors were attacked by mountain lions, they probably experienced acute fear. This fear gave them an extra burst of energy to flee the danger, or, if flight were impossible, to turn and fight.
Today in most parts of the world, there is little danger of attack from wild animals. As areas develop economically and culturally, these kinds of acute dangers are systematically eliminated or at least drastically reduced. Close encounters with tornadoes, hurricanes, rattlesnakes, car accidents, etc., can still arouse full-blown fear responses, but most people in developed countries can go months – even years – without experiencing these kinds of situations.
Anxiety, however, is a different matter. Anxiety is essentially a fear response that doesn’t quite take off. It is a constant feature of modern life. Just as industrial and commercial development entailed the systematic reduction of acute dangers, it involved an equally systematic increase in situations that provoke anxiety. Indeed, it could be argued that the production and maintenance of anxiety is an integral component of modern marketing.
The purpose of commercials is to generate within people feelings of insecurity and concern. The range of worries that are exploited in this way is limited only by the imaginations of the marketers. From all quarters we are bombarded with anxiety-producing messages, such as: you are not attractive; your television set is too small; your car is too old; your clothes are out of style; your hair is too gray (or oily, or dry); your libido is inadequate; your kitchen is outdated; your breasts are too small (female); your penis is too small (male); your computer is too old; your house needs to be painted; you have too little hair on your head; you have too much hair every where else, etc., etc… The purpose of these messages is to generate within us feelings of anxiety and insecurity so that we will buy more stuff. Of course the “fix” is only temporary, and the process continues pretty much from cradle to grave.
It is not being suggested that the marketers invented anxiety. Our ancestors in the caves probably experienced concern and anxiety if they heard unusual noises from outside the cave at night. This kind of anxiety is useful in that it increases vigilance and prepares the organism for a rapid response should this become necessary. In modern life there are many situations in which a certain amount of anxiety is appropriate and adaptive. On the highway, for instance, a sudden increase in the traffic density usually elicits a measure of anxiety. This anxiety sharpens our attention and helps us avoid mishaps. Similarly, most people will experience some anxiety if caught out in a severe storm, especially in tornado country. These are natural stressors and the anxiety they provoke is appropriate and helpful.
In addition, people who have had unpleasant experiences will likely feel some anxiety if exposed to similar circumstances later in life, and, in fact, will generally go to considerable pains to avoid such circumstances. People, for instance, who were teased and taunted during childhood will often in later life avoid situations where they might be exposed to criticism or ridicule.
What the marketers have done, however, is they have taken this natural adaptive mechanism and exploited it endlessly for their own gain and to the detriment of the public. In this they have been extraordinarily successful, so that at present we experience worry and anxiety – not only with regards to genuine concerns – but also with regards to an enormous range of matters which are truly trivial and inconsequential. What used to be the land of the free and the home of the brave has degenerated into a nation of worriers and fretters. But the fundamental point is that anxiety, in and of itself, is normal – it is an integral part of our normal day-to-day existence, and serves a useful purpose. What the American Psychiatric Association and the pharmaceutical companies have done, however, is redefine anxiety as a pathology – an illness – that needs to be treated by taking pills.
The DSM lists the following anxiety disorders:
Panic disorder without agoraphobia
Panic disorder with agoraphobia
Agoraphobia with out panic disorder
Specific phobia
Social phobia
Obsessive compulsive disorder
Posttraumatic stress disorder
Acute stress disorder
Generalized anxiety disorder
Anxiety disorder due to a general medical condition
Substance induced anxiety disorder
Separation anxiety disorder
Sexual aversion disorder
And of course,
Anxiety disorder not otherwise specified (n.o.s.)
The list is self-explanatory and is designed to cover as wide a range of anxiety-provoking situations as possible. The inclusion of the n.o.s. diagnosis at the end of the list ensures that anyone experiencing anxiety or worry concerning any matter whatsoever can be assigned a diagnosis and can enter the ranks of the “mentally ill.” DSM specifies that for a diagnosis to be made, the anxiety has to “interfere with the person’s functioning” or “cause marked distress”. In practice, these qualifiers are sufficiently vague that virtually anyone can be given an anxiety diagnosis. People who go to counselors for help with stress or life choices are often assigned a diagnosis of Generalized Anxiety Disorder. They are “enrolled” in the ranks of the mentally ill, and their numbers swell the already inflated statistics quoted in the first post (Proliferation of Mental Disorders)
Consider, for instance, a person who for several years has succumbed to the Madison Avenue hype. This individual has bought a new house, a big car, an entertainment center, membership at an expensive country club, etc. Although apparently wealthy, he actually has no money in the bank and is completely dependent on his paycheck to remain solvent. He now receives information that his company is considering lay-offs, and he fears that his name may be on the list. Meanwhile, he discovers that his sixteen-year-old son is doing drugs, his fourteen-year-old daughter is sexually active, and his wife has been “seeing” someone else. Understandably, he is becoming somewhat anxious. In fact, he is beside himself with worry. He’s not sleeping well. He’s gone off his food, and he’s beginning to make serious mistakes in his work. He doesn’t actually see much of his family, but when he does, he finds himself being increasingly irritable and grouchy.
Although this is a purely hypothetical case, there are a great number of people in our society who are living variations of this kind of scenario – sometimes for years on end. Their lives have become untenable, and their anxiety and worry are entirely appropriate. Things are out of control. They need to be worried, and they need to be taking corrective action.
If our hypothetical worrier goes to a mental health practitioner, however, he will be given a diagnosis of Generalized Anxiety Disorder (an invented illness) and a prescription for anti-anxiety pills. He is given the false and destructive message that the problem is simply an illness – a chemical imbalance – and that taking the pills will correct the imbalance in the same way that insulin injections enable a diabetic to function normally. The notion that his life is out of control and that certain fundamental changes need to be made is seldom even addressed.
For an excellent account of how a drug manufacturer promoted generalized anxiety disorder to market a new drug, see Brendan Koerner’s article “Disorders Made to Order” in the July/August 2002 issue of Mother Jones.
The APA’s criteria for a diagnosis of Generalized Anxiety Disorder are listed below:
A. Excessive anxiety and worry (apprehensive expectations), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4) irritability
(5) muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
D. The focus of the anxiety and worry is not confined to features of [another mental disorder]
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance…. or a general medical condition ….or [another mental disorder].
The reader will readily appreciate that our hypothetical worrier described above, and the millions more in the same boat, are easily embraced within the above criteria. If this individual goes to a mental health center, he will be given a “diagnosis” and a prescription for an anxiolytic. The chances are slim that he will receive any counseling with regards to stress reduction, relationships, or lifestyle. The essential message he receives is that his life and his habits are fine, but that he has a “chemical imbalance” in his brain that is causing him to feel upset and worried, and that the pills will take care of it.
In this context, it is important to remember that the vast majority of mental health diagnosing is based on the uncorroborated self-reports of the patient. If you tell a psychiatrist that you are very tense and anxious and that you can’t sleep, can’t focus on your work, and are irritable with your family – and if you make it sound convincing – you will be given a diagnosis of Generalized Anxiety Disorder and a prescription for an anxiety-reducing drug.
The APA and the pharmaceutical companies have jointly developed this spurious system in which all human problems, including normal reactions to stress, are declared mental illnesses which need to be “treated” with drugs. These tactics are focussed on people of all ages and all walks of life. Notice in the criteria for generalized anxiety disorder cited above, how much easier it is to assign this diagnosis to a child (one item instead of three).
Next Post: Posttraumatic Stress Disorder
Conduct Disorder and Oppositional Defiant Disorder
Posted by Phil in A Behavioral Approach to Mental Disorders on April 17th, 2009
CONDUCT DISORDER
The essential feature of Conduct Disorder, according to the APA, is a “repetitive and persistent pattern” of rule breaking or activity which violates other people’s basic rights. The manual identifies four broad categories of behavior under this heading: aggression; destruction of property; theft or deceitfulness; and serious violation of rules.
DSM goes on to state that individuals with this disorder display little concern for the feelings or welfare of others, are frequently callous and indifferent to other people’s pain and loss, and show little in the way of feelings of guilt or remorse. Poor frustration tolerance, irritability, temper tantrums, and recklessness are cited as frequently associated features.
Diagnostic Criteria for Conduct Disorder
The notion that the kinds of serious misbehaviors described above are caused by a mental disorder represents an enormous departure from common sense and conventional wisdom. For this reason, the complete list of DSM criteria are set out below, to enable the reader to clearly assess the APA’s position on this matter. The manual lists the following fifteen items, three of which must have been present in the previous twelve months:
Aggression to people and animals:
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious damage
(9) has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else’s house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years
(14) has run away from home at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
(DSM-IV, 90)
It is clear from these criteria that what is being described here is plain old-fashioned criminality. A serial rapist, for instance, who threatens his victims with a weapon meets criteria 1, 3, and 7, and is therefore suffering from a mental illness. A person who smashes car windows to steal from the glove compartment, who steals from stores, and who bullies and intimidates his family meets criteria 1, 11, and 12, and is also suffering from a mental illness. Just about any kind of criminality you care to imagine is covered by these criteria. In other words, a “diagnosis” of Conduct Disorder means habitual criminality. The APA is not saying that some habitual criminals have a mental illness. Rather, they are saying that habitual criminality in and of itself constitutes a mental illness.
Prevalence
APA’s estimates of prevalence rates are high: 6 to 16% for males, and 2 to 9% for females. DSM goes on to state that Conduct Disorder is “one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children.” The so-called disorder is not confined to children, however, and the manual makes it clear that the diagnosis can be assigned to adults if they meet the criteria.
Former Times
As with most mental health diagnoses, the critical issue is not whether the misbehaviors in question represent serious problems. Clearly they do. Rather, the issue is whether or not they should be conceptualized as mental disorders. Former generations would have used more conventional terms, such as delinquency, villainy, vandalism, crime, brutality, etc., to describe these kinds of activities, and as with ADHD, would for the most part have identified lax or inconsistent parental discipline as the proximate cause. By calling these misbehaviors a mental disorder, the APA is promoting an entirely different way of conceptualizing these problems, and in particular is promoting the notion that these kinds of problems need to be treated by psychiatrists and other mental health workers. The assignment of the diagnosis also implies that the problem is something inherent to the child, and downplays the role of the parents, or indeed of other factors.
The high prevalence rates cited earlier make it clear that the individuals diagnosed with Conduct Disorder represent a sizable proportion of the government statistics mentioned in an earlier post. It is tempting to wonder if politicians and other interested parties who endorse these statistics realize that many of the “afflicted” individuals whose cause they champion are included purely on the basis of a persistent pattern of serious misbehavior and delinquency.
One noteworthy feature of Conduct Disorder is that it has not garnered as much public acceptance as ADHD, even though conceptually there are multiple parallels. The likely reason for this is a recognition on the part of the APA that ascribing such serious misbehavior to a mental disorder would not be palatable to the general public, and that a more lengthy “softening-up” period may be necessary before such a concept would be widely accepted.
OPPOSITIONAL DEFIANT DISORDER
DSM-IV-TR defines Oppositional Defiant Disorder as a “recurrent pattern of negativistic, defiant, disobedient and hostile behavior towards authority figures…” (100), characterized by temper tantrums, arguing with parents and other adults, defiance, refusal to comply with requests and directives, deliberately annoying other people, blaming others for his/her own errors, and being spiteful and vindictive.
The manual lists eight specific criteria, four of which must be present for the diagnosis to be assigned. The eight criteria items are listed below:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults’ requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful and vindictive.
There is little to be said about this so-called mental disorder that has not already been addressed with regards to ADHD and Conduct Disorder. The fundamental question is why this kind of misbehavior, which former generations would have characterized as “being a spoiled brat” should now be considered a mental disorder.
And as with the other so-called mental disorders, the answer is because the APA say so. This is in marked contrast with general medicine, where the identification of a disease usually represents an enormous breakthrough in terms of understanding and treatment. The idea of conventional medical researchers sitting in committees and inventing illnesses by voting and consensus would be considered laughable. Yet that is exactly what the APA has been doing for the past half century with successive revisions of the DSM.
As with other so-called disorders discussed earlier, the diagnosis clearly implies that the problem is something inherent in the child. This effectively lets the parents off the hook, reduces expectations, and in practice encourages a kind of self-centered egotism on the part of the child which usually persists into adulthood. The “disorder” also serves as a portal diagnosis, and typically other mental disorders (e.g., depression, ADHD) are “uncovered” as the child receives “treatment”.
In this context it is worth noting a major weakness of the entire DSM system i.e. the “all or nothing” nature of the so-called diagnoses. In conventional medicine, the all or nothing framework is generally valid. You’ve either got meningitis or you haven’t. There are, of course, degrees to which the infection may have developed, but even a mild case of meningitis is a serious condition, and a dichotomous approach is warranted – not only for treatment/administrative reasons, but also because it accurately reflects the objective reality.
The behaviors outlined above, however, as diagnostic of Oppositional Defiant Disorder are emphatically not dichotomous. Each item very clearly admits of degrees. Consider the first item on the list: “often loses temper”. This could mean anything from a few irate foot-stampings, to wholesale mayhem. Additionally, the word “often” is subject to quantification. Does often mean daily? weekly? monthly? Similar considerations apply to the other items on the list, and to the APA’s requirement of four or more items to make a diagnosis. Why not three, or five?
The fact is that childhood defiance is not a simple unified construct, and is emphatically not dichotomous. It contains multiple components, each of which admits of degrees and could be quantified. In their drive to “medicalize” all human problems, the APA shoehorned this phenomenon into a simplistic yes or no format to facilitate the process of “diagnosis.” The result is not a genuine understanding of the child’s/family’s problem, but a travesty that serves only the interests of the psychiatrists and the pharmaceutical companies. The same criticism can be leveled at almost all the so-called diagnoses in DSM.
Next Post: Anxiety Disorders
Attention Deficit/Hyperactivity Disorder
Posted by Phil in A Behavioral Approach to Mental Disorders on March 31st, 2009
Attention Deficit/Hyperactivity Disorder is defined as “a persistent pattern of inattention and/or hyperimpulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” There is a requirement that the problem existed before age seven and that some of the problems are present in at least two settings. There also must be clear evidence that the inappropriate activity interferes with the individual’s social, academic, or occupational functioning. With regards to the actual diagnostic procedure, the APA lists eighteen behavioral indicators, nine under the heading “inattention,” six under “hyperactivity,” and three under “impulsivity.” For the diagnosis to be considered positive, the child must exhibit at least six problems from either the inattention list or the hyperimpulsivity lists.
Prevalence
DSM-IV-TR (2000) cites a prevalence rate of three to five percent for school-aged children, but even the most cursory familiarity with the reality makes it clear that at least in the U.S., the diagnosis is being assigned with increasing frequency with the passing of years. A CDC study from 2003, for instance, reports a 7.5% nationwide prevalence, the highest rate being in Alabama (11%) and the lowest in Colorado (5%).
Diagnostic Criteria
Attention Deficit/Hyperactivity Disorder is one of the most blatantly abused mental disorder diagnoses and is having an extraordinarily destructive effect within our society. To enable the reader to readily appreciate this matter, and facilitate a discussion, the APA’s eighteen criteria for this fictitious illness are set out below:
Inattention
a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b) often has difficulty sustaining attention in tasks or play activities
c) often does not seem to listen when spoken to directly
d) often does not follow through on instructions, and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e) often has difficulty organizing tasks and activities
f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h) is often easily distracted by extraneous stimuli
i) is often forgetful in daily activities
Hyperactivity/Impulsivity
a) often fidgets with hands or feet, or squirms in seat
b) often leaves seat in classroom or in other situations in which remaining seated is expected
c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness)
d) often has difficulty playing or engaging in leisure activities quietly
e) is often “on the go” or often acts as if “driven by a motor”
f) often talks excessively
g) often blurts out answers before questions have been completed
h) often has difficulty awaiting turn
i) often interrupts or intrudes on others (e.g., butts into conversations or games)
Not A Chemical Imbalance
As with most of the DSM diagnoses, no physical damage or etiology is required for a diagnosis to be assigned. Indeed, with regards to ADHD, DSM acknowledges that there “are no lab tests that have been established as diagnostic in the clinical assessment of” this disorder, nor are there any “specific physical features” associated with it. This is particularly noteworthy in that the notion that ADHD is caused by a malfunction in the brain is widely and actively promoted by psychiatrists and other mental health professionals. Parents, teachers, and other professionals, as well as the general public, are being told that the child can’t pay attention or sit still because of “a chemical imbalance” in the brain. The fact, however, is that there is no evidence to support such contentions, and it is just as reasonable, and far more plausible, to conceptualize the matter as plain, old-fashioned misbehavior. Certainly no one could dispute that problems in brain structure and chemistry can lead to problems in behavior, e.g. Hatfield-McCoy (or Von Hippel-Lindau) disease, but it is equally obvious that problems in behavior can and do occur in the absence of neurological problems. To infer neurological problems purely on the evidence of misbehavior is illogical, unwarranted, and even reckless.
Children who display the misbehaviors listed in the DSM criteria are clearly difficult to manage, and present problems in the classroom and possibly other settings. Parents and teachers are frequently all too relieved to refer these children to a psychiatrist and to accept the chemical imbalance explanation. The psychiatrist prescribes a pill, which by and large keeps the worst of the misbehavior under control. Once again, everybody is off the hook, and the psychiatrists and the pharmaceutical companies are making money.
At the risk of stating the obvious, just because a child doesn’t pay attention, does not mean that he can’t learn to pay attention. There is hardly a child in the world who would not prefer to be outside playing, rather than doing homework or sitting in class learning multiplication tables. Previous generations saw this clearly, and our parents and grandparents accepted the task of teaching their children the necessary skill of applying oneself to difficult and boring tasks and paying attention respectfully to authority figures. Today, tragically, if this training has been neglected, and the child reaches the age of six or seven without this skill, the entirely unwarranted assumption is made that he has a brain problem which prevents him from developing appropriately in this area. The far more likely assumption, that his training and discipline have been blatantly neglected in the home, is almost never even considered.
Former Times
Almost all of the so-called diagnostic criteria listed earlier can be conceptualized as disobedience, laziness, defiance, and misbehavior, and the fact that the misbehaviors are not routinely seen as such is an indication of how far standards have been allowed to slip. The notion that a child of normal intelligence who leaves his seat in the classroom and wanders about the room at will, or climbs or talks excessively, or refuses to wait his turn, or interrupts or intrudes on others, is displaying symptoms of a mental disorder, borders on the bizarre. In former generations expectations were higher. Children who had the temerity to engage in such activity were quickly corrected (usually within the first few weeks of starting school) and readily acquired the appropriate level of self-discipline and control for an academic setting. As the child progressed through the successive grades, expectations were raised, and appropriate correction was provided for problems such as careless mistakes, not listening, not following through on instructions, and avoiding difficult tasks. It might be argued that classrooms in former times were over-regulated and regimented, but there certainly were not large numbers of children routinely misbehaving in the ways listed in the DSM criteria. So either some incredible change has occurred in the brain chemistry of our nation’s children across the last generation or two (which seems unlikely), or else the widespread and highly profitable prescription of psychoactive drugs to control this misbehavior is unwarranted. Nevertheless, these prescriptions have become the standard treatment for this so-called mental disorder.
Circular Explanation
The parent bringing a child to a psychiatrist and asking why he is so restless, why can’t he pay attention, etc., is told “because he has a mental disorder, a chemical imbalance in his brain that prevents him from functioning appropriately in these areas.” If the parent were to push the matter and ask “how do you know he has this disorder, this imbalance?” the only possible response is: “because he is so restless and inattentive.” The “explanation” is entirely circular, and in fact explains nothing. The problem behavior that the APA refer to as ADHD is not something a child has, but rather something he does. It is voluntary behavior which can be trained and modified using the normal methods of parental discipline and control. Parents of children who have been assigned this diagnosis, when confronted with this reality, usually protest that they “have tried everything,” but that their child is simply unamenable to any kind of normal training and correction. In fact, however, what is usually the case with parents in this kind of situation is that they have tried little or nothing in the way of creative discipline and correction, and routinely afford very little time and energy to the task of monitoring and directing their children’s activities. They tend to be extremely unconfident in parenting matters, want to “give” their children as much as possible, routinely fail to say “no” and to enforce sanctions even in situations where this is clearly needed. The mental disorder explanation actively promoted by the psychiatrists and pharmaceutical companies eases their consciences, and the drugs control the worst of the misbehavior. Tragically the child is given the expectation that he is damaged and that he can’t acquire the normal developmental skills in these areas without psychoactive drugs. He is also exposed to an array of side effects that sometimes make the original problem look fairly benign.
Although most parents of these children fit the profile outlined above, there are a few who do not want their children on drugs, and who resist the referral to psychiatric services. The Elementary and Secondary Education Reauthorization Bill, debated in the U.S. Senate and House in October 2001, contained provisions whereby schools could refer children to psychiatrists for mental health treatment only with parental permission. On their website at that time, the APA was actively encouraging readers to contact their political representatives and lobby for the deletion of that particular section of the bill. The question naturally arises as to why the APA would want to see these children without their parents’ permission. The psychiatrists say it’s to ensure that the parents’ resistance does not cause the child to miss out on needed services, but their track record in the marketing and lobbying area, and their ever-vigilant search for ways to expand their services, suggest that their agenda may also have had a more self-centered aspect.
Adult ADHD: A Marketing Success
In the context of marketing, it is worth noting that Attention Deficit/Hyperactivity Disorder is no longer considered exclusively a childhood condition. In recent years adults who exhibit these dysfunctional behaviors are being given the ADHD diagnosis by mental health practitioners, and are being encouraged to think of themselves as having a chemical imbalance in their brain. They are also, of course, being prescribed psychoactive drugs. Like their childhood counterparts, these adults are given the false message that their laziness, inconsideration, and lack of attention are perfectly acceptable, and that problems of this sort can be resolved pharmaceutically without any effort or difficulty on their part.
Success Through Effort
The notion of success through effort and perseverance has been fairly fundamental in western culture. Throughout most of our history successive generations have been encouraged to strive towards high standards in various areas, and there has always been the recognition that this is not easy. Habits of work and application have been encouraged formally and informally throughout our history. The ADHD diagnosis is a direct attack on the notion of success through effort and hard work. The fact is that most parents still take their responsibilities seriously, and teach their children to sit still, pay attention, etc.. Attributing the dysfunctional behavior of the children who do not receive this training to a mental disorder essentially belittles the efforts of the parents who have been successful in this area. It is noteworthy that the phrase “has difficulty” is used four times in the ADHD criteria: “often has difficulty sustaining attention…”; “often has difficulty organizing tasks and activities…”; often has difficulty playing…quietly”; and “often has difficulty awaiting turn.” The assumption being made here is that the child who is misbehaving somehow has more difficulty acquiring the appropriate habits of discipline and self-control than the child who is behaving appropriately. This assumption is entirely unwarranted. The well-behaved child may, in fact, be experiencing enormous difficulty staying on track, but he continues to do so because he has received appropriate training, discipline, correction, etc., from his parents. The chronically misbehaved child, on the other hand, usually has never been exposed to the notion of success through personal effort, and has never received systematic discipline and training in these areas. He does not, in fact, experience any more difficulty waiting his turn than other children. He has simply never been required to make the effort in this or other areas.
ADHD and DisabilityIn 2006, more than half a million children in the US were receiving disability SSI from the Social Security Administration for mental disorders other than retardation. This was 49% of the total number of children receiving benefits for all disabilities. In other words, of all the children receiving disability benefits, 49% were awarded disability status on the basis of mental disorders other than retardation! In 2003, the percentage was 40%. This increase is part of a trend dating back to 1990, when new criteria for establishing childhood disability were put in place. The new criteria focussed on the child’s functioning, where the previous criteria were based more on proven etiology. The SSA website describes these trends in detail and offers this comment:
“A significant portion of the increase in awards involved mental disorders rather than mental retardation, with much attention directed at awards based on attention deficit hyperactivity disorder (ADHD) and various mental disorders manifesting themselves in maladaptive behaviors.”
An interesting sidebar in this area is that the welfare reform legislation passed in 1996 was expected to reduce the number of childhood disability awards. In fact, the number of awards continued to increase after 1997. It is clear both from the figures and from my personal knowledge of the system at the time, that Social Services departments were routinely referring their problem families to the mental health services, where the children could receive a “diagnosis” and be declared disabled. So they came off the welfare roles and went onto the disability roles. It is also my impression from this period that at least some parents were actively coaching their children in the ADHD symptoms to increase the likelihood of a disability determination. If the reader will glance back to the ADHD criteria listed earlier, it will be apparent that coaching of this sort would present no great challenge. What’s particularly interesting here is that a child who was successfully coached and encouraged to display these misbehaviors would really have ADHD. He would not be faking ADHD. The only requirement for a diagnosis is that the child misbehaves in the ways stated. If the child does these things, then he has ADHD, and if the misbehaviors are severe enough, then he will qualify for disability payments. Why he is behaving this way – or how he got to this position – is of no concern. SSI payments vary from state to state, but are usually about $500 per month per child ($640 in California; $476 in Alaska as of 2006.)
The abuse of these so-called diagnoses is a logical outcome of the APA’s spurious taxonomy. The APA’s position is that these misbehaviors are really symptoms of an illness, and that no other evidence is required to establish the diagnosis. Once this notion gains currency, it can be only a matter of time before someone says: “If my child is sick then why can’t he qualify for disability benefits?”
Next Post: Conduct Disorder and Oppositional Defiant Disorder
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