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
Grand Rounds at Codeblog
Posted by Phil in Carnivals and Fesitvals on March 26th, 2009
Grand Rounds is up at codeblog. Plenty of good reading, including an interesting take on fund raising by Duncan Cross at Don’t Walk.
How Can They Just Invent Illnesses?
Posted by Phil in A Behavioral Approach to Mental Disorders on March 25th, 2009
The notion of a professional group such as the APA sitting in their councils and committees inventing illnesses for themselves to treat seems so preposterous that a measure of disbelief on the part of the reader is understandable. In its historical context, however, the development is not so surprising. The original 1952 DSM was very simple and unpretentious, and whilst part of the APA’s motivation in drafting the document was undoubtedly to draw some credibility and respectability to their profession, there is at the same time nothing to suggest any great drive at that time towards aggrandizement or service expansion. However, having agreed in 1952 that neurosis was a form of mental disorder, it was inevitable that subsequent revisions of the manual would attempt to define this feature further and look for subdivisions of the general category. This, of course, is exactly what has happened, and the current version of DSM lists literally dozens of disorders of this sort, although the general term neurosis is no longer used. (For an interesting discussion of this matter, see Karen Franklin’s post at In The News.)
Trichotillomania is a case in point. DSM-IV describes trichotillomania as a mental disorder in which the victim, usually a female child, twists, tangles, and pulls out her hair in a compulsive, habitual manner.
The reality is that children play with their hair, and children also frequently develop dysfunctional and counterproductive habits, such as picking their noses, putting their fingers in their mouths, etc.. It is likely that children have displayed hair-tangling and hair-pulling tendencies since before people lived in caves. Parents from generation to generation have dealt with these kinds of problems as a matter of course, as an integral part of the normal parental responsibilities.
Functional, effective parents intuitively use the normal systems of coaching, teaching, rewards, punishments, etc., in a more or less systematic attempt to instill productive habits in their children and eliminate dysfunctional ones. This includes hair-pulling. Certainly up till a generation or so ago, no parents would have conceptualized this as anything other than a habit, and the matter would have been resolved promptly within the family using natural methods of coaching, encouraging, etc..
Today, however, thanks to the widespread “consciousness raising” of the APA and the pharmaceutical companies, a growing number of parents have accepted the notion that a child displaying this kind of behavior has a mental disorder and needs immediate professional attention. Newspaper ads and free screenings, both paid for by pharmaceutical companies, promote these ideas and frequently suggest that failure to seek prompt treatment may result in matters becoming a good deal worse.
The treatment usually involves a psychotropic prescription, the side effects of which frequently are far more destructive to the child’s health than the original problem. The child is also “enrolled” in the ranks of the mentally disordered, and is given the false notion that it is impossible to deal with life’s normal problems without the assistance of professionals and pills. He or she is well on the road to customer-for-life status, which of course benefits the practitioners and the pharmaceutical companies.
In this context it is important to note that the question “is trichotillomania a mental disorder or not?” becomes meaningless, because there is no definition of a mental disorder other than the one the APA provides. If the APA says something is a mental disorder, then it is, otherwise it is not. There is no external reality to which their findings must conform. By contrast, a geologist, for instance, who asserted that wood is a form of rock would be rebutted on the grounds that wood simply does not have the objective qualities and characteristics of rock, and no amount of discussion or consensus can alter that reality. A psychiatrist, on the other hand, who suggests that road rage, for instance, is a mental disorder, merely has to persuade enough of his colleagues that this is the case, and it will become so by being included in the next edition of DSM. It is the psychiatrists who decide what is a mental disorder, and their general philosophy in this regard for the past fifty years has been “the more the merrier.” A recent editorial in the American Journal of Psychiatry, for instance, asserts that Internet addiction is a mental disorder and should be included in the next edition of DSM.
In general, business has been good for psychiatrists in recent decades. Clients are indeed seeking their help for an increasingly wide range of problems, and it is likely that DSM-V, when it emerges, will list even more mental disorders than the current edition.
Calling a problem a mental disorder obviously does not change the nature of the problem, nor does it provide any special insight into the matter. The fact is that most children play with their hair. For a very small number the habit becomes strong, and they actually tear hair out in significant quantities. When psychiatrists say, “This is a mental disorder,” essentially what they are saying to the parent is, “You can’t take care of this. You must bring this child in for treatment.” The disempowering aspect of the message is not usually articulated, but parents who succumb to these kinds of pressures do in fact become disempowered and ineffective, and usually relegate an increasing measure of their parental responsibilities to the professionals. This, of course, is good for business, but the results in terms of the child’s general development are often far from satisfactory. Furthermore, by defining the problem as something inherent to the child, the system is ignoring the role the parents may have played in the creation and maintenance of the problem, and in general, little or no attempt is made to empower or coach them towards more effective parenting. (For an interesting perspective on this, see codeblog’s post about a day in the children’s psych ward.)
In the context of diagnostic proliferation, it needs to be recognized that psychiatry is a profession, and that the APA’s primary agenda – rhetoric notwithstanding – is to promote the welfare and interests of their members. That’s why the individual psychiatrists join and pay their dues (currently $540 a year). Like other professional groups, they window-dress their documents and their press releases with public welfare platitudes, but also like other professional groups, they protect their own interests and fight tenaciously for their turf.
It should also be acknowledged that in the turf protection area, psychiatrists have enjoyed a great deal of success and have become extraordinarily adept at lobbying legislators and other decision-making bodies in matters that affect psychiatry’s financial interests. In this regard they have had the wholehearted assistance of the pharmaceutical companies, who have used their formidable advertising and lobbying power to full advantage in the drive to develop the mental disorder framework and to promote its acceptance by the American people. Pharmaceutical companies routinely fund most of the “free screenings” for depression and other so-called mental disorders that one sees advertised in the newspapers and on TV. Their funding sources are seldom acknowledged in the ads, but can usually be verified by calling the 800 number and asking where the funding comes from. In addition the pharmaceutical companies donate large quantities of money to organizations sympathetic to their cause, for instance, the National Alliance for the Mentally Ill (NAMI), and have in recent years begun targeting ads for psychotropic drugs directly towards potential patients.
The central theme of this website is that the APA’s framework, in which an increasingly wide number of human problems are conceptualized as mental illnesses and best treated by psychotropic drugs, is spurious and counterproductive. It is a disempowering philosophy that undermines not only the value and integrity of the individual affected, but also saps the strength, vitality, and creativity of our families and communities. In the following posts I will discuss some of these so-called diagnoses in more detail.
Next post: Attention Deficit and Disruptive Behavior Disorders
Psychologists, Social Workers, and Counselors in the Mental Health Field
Posted by Phil in A Behavioral Approach to Mental Disorders on March 19th, 2009
Although psychiatrists are the primary and most influential players in the mental health business, they are not the only professionals involved. Most agencies also employ psychologists, social workers, and counselors, and it is important to recognize how the developments of recent decades have impacted their roles also.
Psychologists are licensed professionals who have studied psychology (that is, human behavior) to doctorate level. They have no medical training. They work in a wide range of settings, including industry and education. Psychologists became involved in mental health work largely because they were instrumental in the development of psychological tests, and the numbers of psychologists employed by hospitals and out-patient agencies increased fairly steadily through the second half of the twentieth century. Despite this apparent acceptance, however, there has always been a measure of tension between the psychiatrists and the psychologists. Some of this derives from conflicting ideologies, but a good deal of it is driven by simple rivalry and competitiveness, and by considerations of “who’s in charge.” Psychiatrists have consistently attempted to relegate the psychologists to an assistant or underling role, whilst the psychologists have striven for independent status. These tensions continue to this day, and in fact have gained a measure of prominence as psychologists lobby vigorously for prescription rights against the vehement opposition of the psychiatrists.
It is particularly noteworthy, however, that despite these long-standing rivalries, most psychologists working in the mental health field accept, use, and endorse the APA’s diagnostic manual. New candidates to the profession are required to be very familiar with the manual’s content, and the national psychologist licensing examination always contains a large number of questions based directly on DSM material. Psychologists’ acceptance of DSM is driven primarily, of course, by economics. Thanks largely to intensive lobbying over many decades by the psychiatrists, the diagnostic system is recognized by Medicare and by the private insurance companies, and if psychologists want to be reimbursed for their services by these payers, they must use the same system.
Clinical social workers and counselors are in essentially the same position, and despite any ideological objections they might have to DSM, if they wish to make a living in the mental health field, they must also endorse and use the DSM labels and categories. Economics makes cowards of us all.
Many psychologists, social workers, and counselors attempt to rationalize and justify this activity as a mere bureaucratic necessity. The diagnosis, it is argued, is just something that needs to be written on the billing form, and that, within the context of treatment, they continue to follow their principles and to do what they think is right.
There is merit to this argument, of course, but it does not override the fact that when they sign their bills, they are certifying that the client has a mental disorder, and they are lending their support to the spurious notion that mental disorders are the underlying cause of human problems and have reached epidemic proportions in our society. An interesting but important point in this area is that in a great many cases, the client is not informed that he has been assigned a mental disorder diagnosis. A person might seek help from a psychologist or counselor because he is feeling overwhelmed by stress at home or work. He goes along for five or six sessions, talks out his problems, feels better, and is pleased to learn that his insurance company picked up eighty percent of the tab. What he may not realize is that his insurance company paid the bill on the basis of the assigned diagnosis, and that this mental disorder diagnosis now constitutes a part of his insurance record. He has also joined the ranks of the “one fifth of the population” cited in the earlier government statistics.
Next Post: How can they just invent illnesses?
Grand Rounds At APC Internist
Posted by Phil in Carnivals and Fesitvals on March 16th, 2009
Ryan DuBosar at the APC Internist has hosted a great grand rounds this week, with the best that the medical blogosphere has to offer. He followed a newspaper format, and there’s even a funnies section. Head over and check it out.
Psychiatrists and the Pharmaceutical Companies
Posted by Phil in A Behavioral Approach to Mental Disorders on March 14th, 2009
Psychiatrists are medical doctors who after graduation from medical school specialize in the treatment of mental disorders. In 1950 there were about 7000 psychiatrists in the United States. Most of these worked either in the state mental hospitals or in private practice, and in both settings treatment was conceptualized primarily on the lines of talking to the patients, gaining an understanding of their problems, and encouraging them in positive directions.
In the hospitals, considerations of containment and control sometimes eclipsed those of treatment, but in their private practices psychiatrists practiced the newly emerging art of psychotherapy with vigor and enthusiasm. Different schools of thought emerged, and there existed a healthy measure of dialog and debate as to the merits and demerits of various techniques. Articles were published in learned journals, and in every respect psychiatry was poised for development as a “talking” profession.
Despite the enthusiasm with which the psychotherapeutic movement was being greeted generally, it was not without its critics. Physicians generally had always been somewhat skeptical of their psychiatric cousins, but now as the other medical specialties aligned themselves increasingly with the physical sciences, and developed an array of formal tests and procedures to complement their healing arts, the psychiatrists began to feel increasingly self-conscious with regards to the somewhat nebulous and ill-defined nature of their subject matter.
At about the same time, many industrial and commercial organizations in the United States began to offer medical insurance as a fringe benefit to attract employees. Physicians quickly discovered that their bills were paid more reliably and more promptly under these schemes, and not surprisingly, the psychiatrists began to look for ways whereby they also could bill insurance companies for their services. Because of the time-consuming nature of psychotherapy, it was at that time, apart from the state hospitals, almost exclusively the province of the wealthy. Human nature being what it is, however, it is reasonable to believe that psychiatrists had as much difficulty collecting their accounts as other physicians, and their desire to improve their lot in this regard is certainly understandable.
To bill insurance companies, however, they had to specify more clearly than previously what illnesses and disease entities they were purportedly treating. An additional pressure to formalize psychiatric diagnoses arose within the armed forces, where unprecedentedly large numbers of individuals were receiving psychiatric services and where military formalities and accounting were demanding a higher level of precision and definition than psychiatrists had encountered in civilian life. For all of these reasons, the psychiatrists had to produce a formal list of diagnoses, and in 1952, the American Psychiatric Association (APA) published its Diagnostic and Statistical Manual (DSM). The work was not very precise and the diagnostic categories were not clearly defined, but it was a start, and more importantly, the formal endorsement of the APA afforded the diagnoses a respectability and perceived validity that they would not otherwise have achieved.
The first DSM listed four broad categories of mental disorder: psychosis; neurosis; character problems; and psycho-physiological problems. Psychosis embraced what a lay person might term “craziness.” Neurosis referred to worries, anxieties, and depression. Character problems meant bad habits, and psycho-physiological problems referred to mental problems which were believed to be caused primarily by physical factors.
What is especially noteworthy about this early list of mental disorders is that there is no expansionist agenda evident. It was simply an attempt on the part of a helping professional group to codify and systematize the object of their study. They were describing the problems brought to them by their current clientele, and there is nothing in the text to suggest any preoccupation with expanding the diagnostic categories to embrace large numbers of new clients.
By contrast, the current edition of the APA’s manual, DSM-IV, published in 1994, has more than three hundred diagnostic categories and sub-categories, and it is difficult to avoid the perception of expansionist marketing. In addition, the diagnostic categories are so vaguely defined that almost anybody at some time in his or her life will meet the criteria for at least one mental disorder.
To understand how such a major shift in emphasis occurred, it is necessary to examine the role of the pharmaceutical companies.
In the 1950’s, several psychotropic drugs were discovered or invented, and it was clear that further developments in this area were imminent. Psychotropic drugs are chemicals that alter people’s behavior and/or mood, and it was also clear that the sales potential in this area was enormous.
The problem for the pharmaceutical companies, however, was that they needed diseases and illnesses for which these drugs could legitimately be prescribed. In the United States the testing and marketing of drugs is regulated by the Food and Drug Administration (FDA), and part of the regulatory process requires the manufacturer to specify the illness targeted by a new drug and to conduct appropriate clinical trials. The testing procedures are not as rigorous as the public generally believes, but obviously they cannot be completely ignored.
So as the second half of the twentieth century was under way, we had the APA, on the one hand, formalizing and codifying the disorders or illnesses that their members are treating in their daily practices. On the other hand the pharmaceutical companies were looking for illnesses which would legitimize the sale and distribution of their newly discovered psychoactive products. The mutual interests were obvious. The psychiatrists and pharmaceutical companies joined hands in a collaborative venture that flourishes to the present day. The major impact of the “merger” on the psychiatrists is that the nature of their work changed from psychotherapy, which consisted essentially of talking and listening, to prescribing pills. At the present time it is extremely rare to find a psychiatrist who has ever practiced or even received training in any form of “talk” therapy. For the most part a psychiatrist’s workday consists of a succession of fifteen-minute “med checks”: routine interviews for the purpose of renewing psychoactive prescriptions.
Most psychiatrists seem comfortable with this role. They can see more clients and therefore generate more income than their colleagues of former years, and for many the pills and the codified diagnoses lend a “scientific” legitimacy to their activity that they feel was absent in the days of psychotherapy. Successive revisions of DSM have enormously expanded the potential client population to the point where psychiatric services (in other words, psychoactive drugs) are now being actively promoted and advertised for every age group and virtually every problem of human life. It is the pharmaceutical companies, of course, who drive these drug promotion campaigns, the success of which is clearly evident. In the meantime, the number of psychiatrists in the US has risen to over 45,500, a six fold increase since 1950.
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