Tag Archives: expansion of psychiatric turf

Sluggish Cognitive Tempo – A New Diagnosis?

On April 11, 2014, journalist Alan Schwarz (brief bio here) published an article in the New York Times on this topic, titled Idea of New attention Disorder Spurs Research, and Debate.  Alan has written extensively on the rising rates of the condition known as ADHD, and on the abuse of the drugs that are used to “treat” this condition. He has drawn a good deal of criticism from psychiatry’s believers.

In the NY Times article Alan draws attention to the fact that sluggish cognitive tempo (SCT) is being promoted as a new disorder  “… characterized by lethargy, daydreaming and slow mental processing.”  He makes the obviously valid point, that the formalization of such an entity  “… could vastly expand the ranks of young people treated for attention problems.”

The NY Times article was prompted by the fact that the Journal of Abnormal Psychology featured this emerging “diagnosis” in its January 2014 issue.  The issue contained eleven articles on the topic.  These articles addressed questions like:

  • Is SCT a sub-domain of ADHD?
  • Is SCT a disorder in its own right?
  • What are the symptoms of SCT?
  • What are SCT’s co-morbidities?
  • In what ways does SCT differ from ADHD, inattention type?
  • How does SCT differ from depression and anxiety, etc.?

It is a central theme of this website that mental illnesses/disorders, including ADHD and SCT, have no ontological or explanatory significance, are not a helpful way to conceptualize human existence, and in fact are intrinsically disempowering and stigmatizing.  The fact that these so-called illnesses are adduced by their psychiatric inventors to legitimize toxic treatments adds to their destructiveness.  The details of these critiques need not be repeated here.

HISTORY OF SCT

Sluggish cognitive tempo is not a new concept.  ADHD has long been criticized, even by psychiatrists, as embracing two very different kinds of presentations:  inattentiveness, on the one hand, and hyperactivity/impulsivity on the other.  DSM-III-R (1987) acknowledged this problem and created the new “diagnosis” 314.00 Undifferentiated Attention-Deficit Disorder (p 95).  The manual describes this condition as follows:

“This is a residual category for disturbances in which the predominant feature is the persistence of developmentally inappropriate and marked inattention that is not a symptom of another disorder, such as Mental Retardation or Attention-deficit Hyperactivity Disorder, or of a disorganized and chaotic environment.” [Emphasis added]

DSM-IV (1994) also acknowledged this issue, and split ADHD into three distinct “diagnoses.”

  • ADHD Combined type
  • ADHD Predominantly inattentive type
  • ADHD Predominantly hyperactive-impulsive type

DSM-IV-TR (2000) created the “diagnosis” 314.9  Attention –Deficit/Hyperactivity Disorder Not Otherwise Specified

“This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.  Examples include:

1.  Individuals whose symptoms and impairment meet the criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type but whose age at onset is 7 years or after.

2. Individuals with clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria of the disorder but have a behavioral pattern marked by sluggishness, daydreaming, and hypoactivity.” [Emphasis added]

DSM-5 has two residual categories in this area:

  • Other Specified ADHD (314.01)
  • Unspecified ADHD (314.01)

These “diagnoses” do not mention sluggishness, daydreaming and hypoactivity specifically, but these attributes are clearly embraced by the definitions.  This is particularly the case in that practitioners working with DSM-IV-TR would have become accustomed to conceptualizing this particular presentation as a “sub-diagnosis” of ADHD and, in addition, DSM-5 did not repudiate the SCT example given in DSM-IV-TR.  DSM-5 offers no examples of the residual diagnoses, the most reasonable interpretation of which is that the older examples are still to be considered valid as well as any others that individual practitioners encounter/invent as they go about their work.

It is noteworthy also that the DSM-5 main entry on ADHD contains the phrases: “mind seems elsewhere” and “may include unrelated thoughts.”  These phrases did not occur in the DSM-IV-TR main entry, and are clearly intended to embrace the notion of daydreaming.

So it is clear that the APA’s notion of ADHD (predominantly inattentive type) has long embraced daydreaming and lethargy, and it was probably inevitable that psychiatry, with its ever-expanding agenda, would eventually begin to conceptualize this as a distinct “illness.”  So today we have sluggish cognitive tempo emerging as a “diagnosis” in its own right, and attracting comment and attention.

CURRENT STATUS OF SCT

Earlier this year, Catherine Saxbe MD, a psychiatrist, and Russell Barkley PhD, a psychologist, wrote a paper reviewing the history of research on sluggish cognitive tempo.  The paper, The second attention disorder? Sluggish cognitive tempo vs. attention-deficit/hyperactivity disorder: update for clinicians, was published in the Journal of Psychiatric Practice.  Here’s a quote:

“Sluggish cognitive tempo (SCT) refers to an impairment of attention in hypoactive-appearing individuals that first presents in childhood. At this time, it exists only as a research entity that has yet to debut in official diagnostic taxonomies. However, it seems likely that a constellation of characteristic features of SCT may form the criteria for a newly defined childhood disorder in the foreseeable future, provided limitations in the extant findings can be addressed by future research.”

The authors expressed the belief that sluggish cognitive tempo is an unfortunate name for the disorder  “…since the term sluggish is associated with connotations of being retarded, slow-witted or just plain lazy.”  They remind us that

“More than semantics is at stake here.  The nosology reflects the way we conceptualize a disorder, view our patients, and how they understand themselves.”

They suggest that “concentration deficit disorder” or “developmental concentration disorder” or “focused attention disorder” would be better names for the problem, and appear to be entirely blind to the fact that the negative effects of referring to a child as “sluggish” pale to nothing compared with the stigma and disempowerment inherent in the notion that he is a “patient” with a “mental illness” (regardless of the name given to this illness).  In addition to which, of course, must be reckoned the destructive effects of the “treatments.”

Here are some more quotes from the Saxbe and Barkley article:

“No large-scale medication trials have examined response to stimulants specifically in SCT, but one recent investigation shows promise for the potential use of atomoxetine.”

and

“This is an exciting finding and warrants further investigation as it is the first published report to show improvement in SCT with any medication.”

and

“Given the overlap of SCT with anxiety and depression, perhaps selective serotonin reuptake inhibitors (SSRIs) might be [another] possible treatment.”

The study in question is Wietecha L. et al., titled Atomoxetine improved attention in children and adolescents with attention-deficit/hyperactivity disorder and dyslexia in a 16 week, acute, randomized, double-blind trial.  This appeared in the November 2013 issue of Journal of Child and Adolescent Psychopharmacology.  The paper is a study of the efficacy of atomoxetine in the “treatment” of various attention problems including SCT.  Atomoxetine is a selective norepinephrine reuptake inhibitor (NRI) marketed as Strattera by Eli Lilly.  The study (Wietecha et al.) found that:

“The atomoxetine-treated ADHD-only subjects significantly improved from baseline to Week 32 on…all K-SCT [Kiddie-Sluggish Cognitive Tempo Interview] subscales…”

and

“This is the first study to report significant effects of any medication on SCT.”

All of this is particularly interesting because:

  1. Ritalin, which is now off patent, and other stimulants, are reportedly ineffective in the “treatment” of SCT “symptoms.” (Saxbe and Barkley, 2014, p. 47)
  2. Atomoxetine, which is still on-patent, is now “proven” effective in this area.
  3. Linda Wietecha works as a Clinical Research Scientist for Lilly USA, LLC
  4. According to Dollars for Docs, the following co-authors on the study have also received money from Eli Lilly in the period 2009-2012: Bennett Shaywitz, MD, $963,003; Stephen Hooper, PhD, $16,540; David Dunn, MD, $56,886; and Keith McBurnett, PhD, $5,000.
  5. Russell Barkley, PhD, co-author of the article cited earlier, received $120,283 from Eli Lilly for consulting, speaking, and travel between 2009 and 2012 (Dollars for Docs), and as recently as February of this year gave a lecture tour in Japan sponsored by Eli Lilly.

All of which raises the interesting question:  is SCT disorder being promoted at the present time by Eli Lilly’s paid hacks as a way of increasing sales of atomoxetine (Strattera) while it is still on patent?

PSYCHIATRIC CREDIBILITY

Interestingly, and sadly, most of the research and promotion of SCT has been done by psychologists rather than psychiatrists.  This fact prompted Jeffrey Lieberman, MD, President of the APA, and very eminent psychiatrist to  tweet on April 11 “no credible psychiatrist takes this [SCT] seriously” in response to Alan Schwartz’s article in the New York Times.  Dr. Lieberman seems to be unaware that in DSM-IV-TR (2000), the APA created a specific “diagnosis” for the sluggishness/daydreaming/hypoactivity presentation (using those exact words), and that this “diagnosis” has been clearly retained in DSM-5 (though without those specific words).  I’ve never been aware of any great outcry from organized psychiatry, or from individual practitioners, on this matter.  So, if we are to take Dr. Lieberman at his word (and why would we not do that?), there must be an enormous dearth of “credible psychiatrists” within the APA’s ranks.

In this context, it is also noteworthy that the Wietecha et al. article was published in the Journal of Child and Adolescent Psychopharmacology, which suggests – at least to me – that the journal takes SCT seriously.  The editor-in-chief is Harold Koplewicz, MD, psychiatrist, founding member and President of the Child Mind Institute.  Dr. Koplewicz has held many prestigious positions, and has received numerous awards, including the 2009 American Psychiatric Association McGavin Award for lifetime contributions to child psychiatry.  But alas, he must now be considered a psychiatrist with no credibility.

And

The Saxbe and Barkley article was published by the Journal of Psychiatric Practice, the editor of which is John Oldham, MD, Senior VP and Chief of Staff at the Menninger Clinic, and a psychiatry professor at Baylor College of Medicine.  Dr. Oldham is a past President of the APA (2010-2011), and of the American College of Psychiatrists (2010-2011).  He has also been President of the International Society for the Study of Personality Disorders, and was a member of the DSM-5 Personality Disorders workgroup.  But, here again, no credibility!

The general point here is that psychiatry has embraced the concept of medicalizing daydreaming. Dr. Lieberman either doesn’t realize this, or is trying to conceal the fact.

DISCUSSION

It would be easy to get distracted by this recent attempt to promote childhood daydreaming as a mental illness.  As mentioned earlier, daydreaming, or to use psychiatric terminology, “the persistence of developmentally inappropriate and marked inattention,” has been a specific “mental illness” since DSM-III-R, 1987, (p 95).

The fact is that any human presentation can be considered a mental illness.  All that is needed is the APA’s say so.  And the APA made their position absolutely clear in the foreword to DSM-II (1968).  In the paragraph where they discuss what “diagnoses” should be included in the manual, they state:

“The Committee has attempted to put down what it judges to be generally agreed upon by well-informed psychiatrists today.” (p viii)

In other words:  if we say it’s a mental illness, then it’s a mental illness!

In subsequent editions of the manual, they offer a definition of a mental disorder, which when stripped of verbiage boils down to:  any significant problem of thinking, feeling, and/or behaving.  And who decides something is a problem?  A psychiatrist, of course.

Sluggish Cognitive Tempo (or concentration deficit disorder, as Drs. Barkley and Saxbe would prefer to call it) is more psychiatric nonsense.  But that’s all it is – more of the same; another inevitable result of psychiatry’s fundamentally flawed, spurious, and destructive medicalization of human existence.  Psychiatry continues to expand its net of entrapment into all aspects of life and into every corner of the globe.

By all means let’s speak out against this latest encroachment, but let us not lose sight of the corrupt and spurious engine that has been driving this endeavor since the 1950’s, or of the trail of human suffering and destruction that it has left, and continues to leave, in its wake.

Nor let use lose sight of the fact that many of the greatest writers, scientists, and artists were chronic daydreamers.  We can only imagine how much better the world would be today if these individuals had received the benefits of modern psychiatric treatment. We can also look forward to a better future – a future where daydreaming will be routinely recognized as the illness that it is, it’s victims will be “treated” appropriately with psychiatric drugs, and this plague, that has beset humanity since pre-historic times, will finally be eradicated.

* * * * * * * * *

There is absolutely no facet of human existence that psychiatry will not pathologize in the pursuit of its own self-serving agenda.

‘ADHD’ and Dangerous Driving

In 2006, Laurence Jerome, a Canadian psychiatrist, and two colleagues wrote a paper titled What We Know About ADHD and Driving Risk: A Literature Review, Meta-Analysis and Critique.  It was published in the Journal of the Canadian Academy of Child and Adolescent Psychiatry in August, 2006. The primary result of the meta-analysis was:

“Current data support the utility of stimulant medication in improving driving performance in younger ADHD drivers.”

The study is lengthy and well-referenced, but in keeping with standard psychiatric practice, it conceptualizes and presents ADHD as a “…common psychiatric disorder…” with symptoms of “…inattention, impulsiveness and hyperactivity…”  In other words, they present ADHD as something that a person has rather than as something that a person does. The problem with this approach is that it creates the impression that meaningful or significant correlations/effects have been found, where in fact all that has happened is an elucidation of the terms used.

For instance, the authors refer to a study by Fried et al. (2006) and state:

“Fried et al. (2006) evaluated driving behavior using the DBQ [Driving Behavior Questionnaire] and found that the ADHD group had significantly more lapses, errors and violations than controls.”

On the face of it, this looks like an interesting finding.  It purports to be an important fact that has been discovered about people who have this condition.  But in reality, lapses, errors, and violations are an integral part of the definition of ADHD.  The DSM criteria includes:  careless mistakes; difficulty remaining focused; mind seems elsewhere; easily distracted; forgetful; etc…  One doesn’t get into this group in the first place without a history of habitual lapses, errors, and violations.  The fact that these habitual lapses and errors carry over into a person’s driving behavior isn’t particularly surprising.

There are several other examples of this in Jerome et al., e.g.:

“A number of studies examined cognitive abilities associated with safe driving performance. Measures of both inattention and impulsivity were found to be higher in the ADHD groups as compared to controls.”

Here again, inattention and impulsivity are defining features of the condition labeled ADHD.  All that has actually been found here is that people who are inattentive and impulsive are inattentive and impulsive! The study reports that people who carry a “diagnosis” of ADHD are involved in more collisions, and receive more traffic citations than controls.  This is interesting, but again, hardly surprising for the reasons discussed above.  One could look at all this simply as benign, meaningless verbiage, but in reality, the constant repetition of these factoids reinforces the notion that the label ADHD refers to a real illness, and that this “illness” has real sequelae, in the same way that kidney failure, for instance, usually entails edema and anemia.

EFFECTS OF PSYCHOTROPIC DRUGS

The authors discuss several studies on the effects that stimulant and non-stimulant drugs that are used to “treat” ADHD have on driving behavior.  The results were mixed.  The authors draw attention to some methodological problems in this area and also concede that “…all currently available studies are industry sponsored.”

NEUROLOGY

Dr. Jerome et al. posit a neurological deficit as the source of the impulsivity and inattention.

“Core functional impairments in executive function related to response inhibition, working memory and flexible strategic response help explain both general ADHD pathology and its specific manifestations in problem driving in this group.”

This paper, as noted earlier, was written in 2006.  Note the cautious language in the quote above:  “…help explain…”  Today, eight years later, there’s still no definitive neural pathology known to be causally associated with these problem behaviors, and the “illness” is still being “diagnosed” by subjectively assessing, and counting, the individual’s actions.  In fact, and this is particularly compelling, the American Academy of Child and Adolescent Psychiatry in its current practice parameters for ADHD state unambiguously that unless there is a clear history of severe head injury, or other neural pathology

“…neurological studies…are not indicated for the evaluation of ADHD.” [Emphasis added]

At this point Dr. Jerome et al. make the great leap of faith:

“…it was not the knowledge base of driving skills that differentiated the driving problems in ADHD youth so much as their inability to apply these rules at the appropriate time and under the appropriate circumstances. In other words the problem is an output problem; they can ‘talk the talk but they can’t walk the walk’.” [Emphases added]

Note the words “inability” and “can’t.”  This is one of the fundamental problems in the “diagnosis” of ADHD and other psychiatric “illnesses” – the logically flawed leap from “doesn’t” to “can’t.”  And this unwarranted leap is the basis for the conclusion that the individuals in question have an illness, and, in extreme cases qualify for disability.  A person with kidney failure doesn’t and can’t produce urine.  But a person “with” ADHD can, with proper training, learn to behave in a more attentive and less impulsive manner.

In former times, children who were routinely inattentive and impulsive were considered to be in need of training and discipline.  By and large, school teachers and parents provided this.  In fact, the training was usually provided before the matter even became an issue.  Today these children are spuriously and arbitrarily labeled as ill, and are given pills.  The pills suppress the problem behavior, but in many, perhaps most, cases the underlying problem of self-discipline is never addressed.  So these children grow up and, not surprisingly, they become inattentive and impulsive drivers, with a reportedly 50% increased risk of negative driving outcomes.  The “diagnosis” of “illness” contains within itself the disempowering, and incidentally false, message that the individual was incapable of acquiring the level of discipline, attention, and self-control needed for successful classroom participation.  Psychiatry has given these parents, and the children themselves, the false message that their brains are malfunctioning, that the pills will correct the problem, and that attempts to teach discipline and self-control in the normal manner are futile.  With pharma-psychiatry’s successful expansion of this “diagnosis” to the adult population, the disempowerment has become a more-or-less permanent “disability.”

The role that the initial “diagnosis” and subsequent drugging played in transforming what used to be an eminently remediable problem into a permanent disability is seldom addressed or even acknowledged.  The psychiatric fiction has to be maintained:  these individuals were “sick” as children and are still “sick” as adults.  Their inattention and impulsivity are still “symptoms” of the same debilitating “illness.”  Psychiatrists for the past sixty years have insisted that they are discovering real illnesses.  They remain self-servingly blind to the fact that, firstly, they invented these illnesses, and secondly, that their active promotion of these “illnesses” has created a culture in which personal effort and self-discipline are routinely marginalized in favor of the spurious and inherently disempowering notion of pharmaceutically correctable impairments.

Jerome et al. do pay passing acknowledgement to the need for “psychological strategies,” but it is clear that they conceptualize the matter as a medical problem with a pharmaceutical remedy:

“Experimental studies indicate that stimulants and to a lesser extent non-stimulant drugs used to treat ADHD improve areas of driving performance.”

These, incidentally, are the same industry-sponsored studies mentioned earlier.

and

“In particular the question of adherence to medication regimens over time to improve driving skills is likely to be a critical question based on our knowledge of poor long-term medication adherence for young adults with ADHD.”

and

“The individual attending physician has an opportunity to reduce morbidity and mortality for the individual ADHD patient as well as contribute to improved public health for the driving population at large by making the roads safer one driver at a time.”

and

“A number of jurisdictions including Canada and UK now require physicians to report ADHD drivers thought to be at risk of problem driving to the Ministry of Transportation.”

and

“The question of medico-legal liability is in its infancy with no established case law for physicians found negligent of failing to adequately treat ADHD patients with the appropriate medications to reduce driving risk. Whilst the available literature does not yet provide clear evidence that stimulant medication should be the standard of care for problem drivers long term, it is probably only a matter of time before this question will be debated in a legal arena.”

DISCUSSION

At the present time the pharma-psychiatric system is being widely exposed as the spurious, destructive, disempowering fraud that it is.  Organized psychiatry is responding to these criticisms not by cleaning up its act, but instead by increasing its lobbying activity in the political arena.

In particular, they are actively promoting the notion of involuntary community “treatment” with coerced “medication.”  Under this system, which is established by law in more than 40 US states, a judge can order an individual to attend the local mental health center and to abide by the center’s “treatment” plan.  The plan usually entails a requirement to take psychiatric drugs, sometimes the long-lasting injectable variety.  Here’s how Jeffrey Lieberman, MD, President of the APA, describes the program:

“There’s also other forms of psycho-social treatment that are very, very helpful. Sometimes people who have schizophrenia don’t want treatment, or don’t feel they need treatment, or just plain forget about treatment. In those cases, with what’s called assertive community treatment, a case manager or somebody that’s assigned to work with that person will go out to find them, will go to their home, you know, ‘You haven’t come to the clinic, you haven’t come to the office, you haven’t shown up, what’s going on here, you need to get your medication, you need to go through your rehabilitation,’ so they’ll get after them.”

This all sounds very cozy and friendly, and you know – come on down to the mental health center, you know, we care about you, etc., etc… But within the silk glove, there’s the mailed fist of confinement and coerced drugging.  Readers can check out the other side of the story at National Coalition for Mental Health Recovery, PsychRights page on OutPatient Commitment, and by searching for assertive outpatient commitment on Mad in America.  Dr. Lieberman is talking about people labeled with schizophrenia, but it doesn’t take too much imagination to see how the concept could be adapted to a wide range of other “diagnoses,” including ADHD.

As of yet, the ominous prediction in the final Jerome et al. quote above has not come to pass.  But is the day approaching when individuals “diagnosed” with ADHD during childhood will be subjected to special screening when they apply for a driving license?  Might their licenses be made contingent on their ingestion of psychoactive drugs?  After all, impulsive, inattentive drivers constitute a danger to themselves and others.  If, as psychiatry claims, their impulsivity and inattention are the result of a “mental illness,” then doesn’t it make sense that they be committed?  Isn’t it in their own interests and the interests of the public at large that they be coerced to take their “medications”? Such a move would be consistent with psychiatry’s long-standing expansionist agenda and with pharma’s objective to sell more drugs.

And lest my concerns be considered groundless speculation, here are some interesting quotes.

From Oren Mason, MD, a blogger physician, co-owner of Attention MD, and associate professor at Michigan State University.  He specializes in the “…diagnosis and management of attention deficit disorders and related conditions” (Ritalin Saves Truckers’ Lives. Soccer Moms’, Too, February 2014):

“There is a public health issue when inattentive or impulsive behaviors occur on busy, public streets and highways.”

and

“…we could potentially prevent 100,000 injuries and deaths every year with consistent use of ADHD medications.”

Incidentally, according to Dollars for Docs, Dr. Mason received $208,459 from Eli Lilly for speaking, consulting, travel, and meals between 2009 and 2012.

And from Brian Krans, an assistant editor at HealthLine News (Could Ritalin Be the Way to Keep Truckers Safe on the Road? January 2014):

“Another new study says that undiagnosed attention-deficit hyperactivity disorder (ADHD) may be the cause of many safety issues for drivers on the road.”

Note how ADHD has become the cause of the problem behaviors, rather than just another name for them.

and

“… research shows that medications like Ritalin and Adderall may be beneficial to help them increase reaction time [presumably should read decrease], reduce accidents, and ultimately save lives.

Interestingly, Healthline.com runs a good many ads for ADHD “medications.”  They are clearly marked Advertisement, but the font is very small.

and

“So, should truckers be screened for ADHD instead of self-medicating with harder drugs?”

There is an implication here that ADHD “meds” will reduce the incidence of truckers driving under the influence of speed.  In fact, Ritalin and most other ADHD “meds” are stimulants and are widely abused.  RitalinAbuseHelp.com states that

“Ritalin is taken by recreational drug users for its cocaine-like high.”

and

“Ritalin is taken by workers such as truck drivers to stay awake for long shifts.” [Emphasis added]

Here are some more interesting quotes:

From the American Academy of Pediatrics 2011 practice guidelines on ADHD:

“Given the inherent risks of driving by adolescents with ADHD, special concern should be taken to provide medication coverage for symptom control while driving.  Longer-acting or late-afternoon, short-acting medications might be helpful in this regard.”

And from the American Academy of Child and Adolescent Psychiatry: ADHD Practice Parameters:

“Single daily dosing is associated with greater compliance for all types of medication, and long-acting MPH [methylphenidate] may improve driving performance in adolescents relative to short-acting MPH…”

And from psychologist Russell A. Barkley, PhD, Clinical Professor of Psychiatry and Pediatrics at the Medical University of South Carolina in Charleston, and author of numerous books and studies on ADHD, quoted in this New York Times article from 2012:

“Medication [for drivers who have ADHD] should not really be optional…”

And Dr. Barkley is an eminent man.  I know this because on his website it says that he is “…an internationally recognized authority on attention deficit hyperactivity disorder (ADHD or ADD) in children and adults…”  I also know that he is conscientious and caring.  His website states that he “…has dedicated his career to widely disseminating science-based information about ADHD.”  If proof is needed of his dedication to disseminating information, one need only open the “books” tab on his website.  He has 16 different titles for sale at prices ranging from $14.41 for some paperback book versions to $131.75 for his rating scale books.  One can also subscribe to his newsletter ADHD Report for $105 per year.

Dr. Barkley is well regarded by the pharmaceutical industry.  Dollars for Docs reports that between 2009 and 2012, he received $120,283 from Eli Lilly alone, for consulting, speaking and traveling.  In February of this year he conducted a five-day, multi-city lecture tour of Japan sponsored by Eli Lilly.  And according to  his CV, in 2004-2005, he was awarded a grant of $99,750 from Eli Lilly to study the “Effects of atomoxetine on driving performance in adults with ADHD.”

Dr. Barkley has also reportedly served as a consultant/speaker to Shire, Medice, Novartis, Janssen-Ortho, and Janssen-Cilag.

Dr. Barkley played a significant role in the relaxing of the age-of-onset criterion from 7 to 12 in DSM-5.  As early as 1997, he and the equally eminent Joseph Biederman, MD co-authored Toward a Broader Definition of the Age-of-Onset Criterion for Attention-Deficit Hyperactivity Disorder (Journal of the American Academy of Child and Adolescent Psychiatry, September 1997).  In this article they state, apparently without the slightest hint of irony:

“We can see no positive benefits of the recommended AOC [age of onset criterion] except that it would certainly limit the number of children (and probably adults) with diagnosed ADHD.  Some special education districts or managed health care companies who might wish to restrict the access of those with ADHD to their services could conceivably see such a restriction as advantageous, but this is purely financial self-interest.”

So, all things considered, when Dr. Barkley tells a New York Times reporter that medication for drivers with ADHD “should not really be optional,” perhaps we should be concerned.

Over the past 60 years, pharma-psychiatry has demonstrated, time and again, that there is no human problem that they can’t exploit for their own benefit and, in the process, make ten times worse.  I will be watching this latest foray into road safety with trepidation.

Justina Pelletier: The Debate Continues

On April 1, 2014, Slate published an online article titled Mitochondrial Disease or Medical Child Abuse?  The author is Brian Palmer.  Slate is a daily, general interest web magazine, founded in 1996, that provides “analysis and commentary about politics, news, business, technology and culture,” and is a subsidiary of the Washington Post.  Brian Palmer is Slate’s “chief explainer.”

As the title suggests, the article tries to explore the central question in Justina’s case:  does she have mitochondrial disease or is she a victim of medical child abuse?  The author does a good job of defining the various terms, unraveling the issues, and presenting both sides of the argument, though on balance he comes down in favor of Boston Children’s Hospital.  Here are some quotes:

“It’s easy to get angry about this scenario—and there are some troubling things about the way the conflict has been managed—but the doctors at Boston Children’s deserve a defense.”

“…the science is complicated. Mitochondrial disease (Justina Pelletier’s original diagnosis) and medical child abuse (the Boston Children’s diagnosis) can look extremely similar. Both can be deadly if not treated properly.”

“‘Mito,’ however, is incredibly difficult to diagnose definitively.”

“Just as Justina Pelletier exhibited some symptoms consistent with mitochondrial disease, her case also has some of the hallmarks of medical child abuse. One of her chief complaints was digestive trouble, the most common symptom among medically abused children. She had gone through extreme surgical procedures, including the placement of a permanent port in her belly to flush her digestive tract. Her parents had engaged in physician shopping, and experts at Boston Children’s felt that Justina’s emotional state improved when her mother left the room.”

“The doctors at Boston Children’s had few options if they really believed in their diagnosis. Just as the treatment for strep throat is antibiotics, the treatment for medical child abuse is separating a child from her parents. Sending Justina Pelletier home would have represented the height of irresponsibility if their diagnosis was correct. One in 10 children who suffers medical abuse eventually dies at the hands of his or her parent.”

Obviously all of these issues have been debated at great length, not only in the courtrooms, but also in the mainstream media and in the blogosphere.  It is likely that these debates will continue, and will be wide-ranging.

But in this post I would like to focus on just one issue.  If the “extreme surgical procedures” that Justina had undergone were an integral part of the alleged “medical child abuse,” why is the surgeon who performed these procedures not being censured or charged?  Are we to believe that this surgeon performed these extreme procedures without valid cause or justification?  Is it plausible that he/she performed these procedures more in response to parental pressure than genuine medical need?

If, as is claimed, Justina was the victim of “medical child abuse,” isn’t it reasonable to consider the surgeon one of the primary perpetrators?  And if not, why not?  In other forms of child abuse, aiders and abettors are routinely taken to task.  Why is medical child abuse different?

It has been widely reported that an abnormal “congenital band” of cartilage, 20 inches long, was removed from Justina’s abdomen in 2010.  This indeed would constitute an “extreme surgical procedure,” but the critical question is:  was it justified?  Is there a pathologist’s report that casts doubt on the need for the surgery?  If not, then what is the relevance of the assertion that she had gone through “extreme surgical procedures.”  It is possible that a surgeon might excise tissue needlessly either to boost his income or even from over-enthusiasm.  But there exists, in the form of the pathology lab, a time-tested safeguard against this sort of excess.

The validity of the concept of medical child abuse in this case hinges, at least to some extent, on a history of surgical procedures which, apparently, in the opinion of psychiatrists were unnecessary and potentially injurious.  But, on the other side of the scale, we have a surgeon excising real tissue and subjecting this tissue, and incidentally his/her own medical judgment, to critical objective scrutiny.  A surgeon who routinely excises benign tissue, or who performs other unnecessary surgeries, will quickly incur some challenges from the hospital’s Q.A. committee, the medical licensing authorities, and ultimately from malpractice trial lawyers.

By contrast, the psychiatrist’s opinion as to the necessity or appropriateness of the surgery is subjected to no objective check whatsoever.  And perhaps therein lies the answer to my earlier question.  If those psychiatrists who allege medical child abuse had to challenge the surgeons who aided and abetted the alleged abuse, it is likely that in  most cases, the surgeon’s judgment would prevail, and another nail would be put in psychiatry’s coffin.  It’s easier by far to lay the blame on the “persistent and deceptive” parents and to absolve the surgeons and other medical specialties by the blanket contention that they were duped.

Justina Pelletier: The Case Continues

On March 25, Joseph Johnston, Juvenile Court Justice in Boston, Massachusetts, issued a disposition order in the case: Care and protection of Justina Pelletier.  The background to the case is well-known.  Justina is 15 years old.

Judge Johnston did not return Justina to the care of her parents, but instead granted permanent custody to the Massachusetts Department of Children and Families (DCF), with a right to review in June.

In paragraph 4, the disposition order states: 

“At trial there was extensive psychiatric and medical testimony.  Voluminous psychiatric and medical records were entered in evidence.  Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder.  On December 20, 2013, this court found the MA DCF sustained its burden by clear and convincing evidence that Justina Pelletier is a child in need of care and protection pursuant to G.L c. 119, §§ 24-26 due to the conduct and inability of her parents, Linda Pelletier and Lou Pelletier, to provide for Justina’s necessary and proper physical, mental, and emotional development.”

This is the substantial finding of the court, and it is noteworthy that there is no mention of the mitochondrial disease which had been Justina’s earlier diagnosis and for which she had been receiving treatment at Tufts Medical Center, Boston. 

The disposition order is somewhat terse and sparing in its tone, but reading between the lines, it seems clear that the court has determined that Justina either does not have mitochondrial disease or that, even if she does have mitochondrial disease, her concern about this matter is inappropriate and excessive.  There is also the suggestion that her parents, Linda and Lou Pelletier, have contributed to Justina’s preoccupations in this regard, and that for this reason, Justina needs to be protected from them.  As in all cases of this kind, a great deal of the information is kept confidential.  So we are inevitably working with incomplete information.

Obviously there are many issues that might be raised, and these are being addressed by others, but I would like to focus here on the “diagnosis” of somatic symptom disorder.

DSM-5 describes somatic symptom disorder as:  “…distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms.”  A “diagnosis” of somatic symptom disorder can be assigned even if the person really does have an actual illness, provided that the person’s response to the symptoms of the illness is excessively distressing and disruptive.

Here are the actual diagnostic criteria as set out on page 311 of DSM-5:

Somatic Symptom Disorder 300.82 Diagnostic Criteria

A.  One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B.  Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

1.  Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2.  Persistently high level of anxiety about health or symptoms.
3.  Excessive time and energy devoted to these symptoms or health concerns.

C.  Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Specify if:

With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.

Specify if:

Persistent:  A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).

Specify current severity:

Mild:  Only one of the symptoms specified in Criterion B is fulfilled.
Moderate:  Two or more of the symptoms specified in Criterion B are fulfilled.
Severe:  Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

CRITERION A

DSM-5 (p 830) defines a symptom as:  “A subjective manifestation of a pathological condition.  Symptoms are reported by the affected individual rather than observed by the examiner.  Compare with SIGN.”  On page 829 they define a sign as:  “An objective manifestation of a pathological condition.  Signs are observed by the examiner rather than reported by the affected individual.  Compare with SYMPTOM.”  This kind of terminology has become standard in general medicine.  A symptom is something reported by the patient (e.g. abdominal pain); a sign is something observed by the examiner (e.g. distended abdomen).  Symptoms and signs are the twin pillars of medical diagnosis.

“Somatic” means bodily or physical, as opposed to mental.

So criterion A requires that the individual reports at least one physical symptom, and that this symptom is distressing and results in significant disruption of daily life.  Distress and significant disruption are vague concepts, the assessment of which is clearly dependent on the psychiatrist’s subjective judgment.

CRITERION B

Here again, we have a great deal of subjectivity.  Words like “excessive” and “disproportionate” are open to individual interpretation, and there are no objective standards by which the accuracy of the diagnostic decision can be assessed.

Ultimately, a person will meet the requirements of criteria A and B if, and because, a psychiatrist says so.  There is no objective reality against which the psychiatrist’s assessment can be checked.  The psychiatrist’s subjective assessment is the only test for a “diagnosis” of somatic symptom disorder.

So when a psychiatrist says that a person “suffers from somatic symptom disorder,” all that this means is:  “In my opinion this individual is excessively preoccupied with physical symptoms and that, also in my opinion, this preoccupation is causing significant disruption in his/her life.”

The APA, by including this “diagnosis” in their diagnostic manual, assigning it a name and number, and listing the diagnostic criteria, create the impression that this is a real illness, and distract attention from the central fact:  that the only reality here is a psychiatrist’s opinion.

The only justification for the assertion that Justina Pelletier “suffers from a persistent and severe Somatic Symptom Disorder” is a psychiatrist’s subjective opinion.  In fact, the statement “Justina suffers from somatic symptom disorder” means:  “A psychiatrist believes that Justina’s concern about her symptoms is excessive.”  These two statements are absolutely equivalent.  The first statement, despite its appearance of objectivity, contains no additional substance over the second.

CONFLICTS OF INTEREST

This deception is the foundation of modern psychiatry.  But it doesn’t just occur at the point of individual assessment.  It also applies to the invention of these illnesses in the first place.  Somatic symptom disorder, like all psychiatric diagnoses, is considered to be an illness because the APA say so.  And individuals are considered to have a particular psychiatric “illness” because an individual psychiatrist says so.  It’s all based on subjective opinion.  And subjective opinion is notoriously unreliable.

But it is particularly unreliable when there are conflicts of interest.  The notion that all significant problems of thinking, feeling, and/or behaving are illnesses is central to the APA’s survival.  When the day comes – as it surely will – that it is recognized that these problems are not illnesses, then psychiatry will go the way of astrology and phrenology.  It will cease to exist.  Psychiatry’s foundation is an enormous deception, and in my view psychiatrists know this.  But they are fighting for their very existence.  The conflict of interest isn’t just about money; it’s also a matter of their professional identity.  As a group, they are so invested in the notion of psychiatric illness that they have rendered themselves incapable of honestly and objectively addressing the question:  are these problems really illnesses?

In this context, psychiatrists frequently point out that diagnoses in general medicine sometimes involve a physician’s opinion.  This is true, but misses the point.  When a real doctor says: In my opinion, this person’s diagnosis is X, what he’s saying is that he’s not 100% sure what the actual physical etiology is, but his best assessment at that point in time is X.  In psychiatric “diagnosis” there is no reality against which the “diagnosis” can be checked.  There is nothing but the psychiatrist’s opinion.

At the present time, small numbers of individual psychiatrists are seeing the light, and are courageously struggling with these conceptual issues.  But organized psychiatry in the form of the APA is actually doubling down and fighting harder than ever to prop up the deception that is crumbling like a sandcastle in a flowing tide.

And, of course, there is a huge conflict of interest for individual psychiatrists during their initial evaluations.  The psychiatrist’s bill, whether it’s sent to a private insurance carrier, or Medicare, or other reimbursing entity, depends for its legitimacy on the diagnosis.  Without a diagnosis, the psychiatrist doesn’t get paid!

So the situation is this:  the “diagnosis” is based entirely on the psychiatrist’s subjective opinion; and the psychiatrist’s paycheck depends entirely on the diagnosis.  Not surprisingly, psychiatrists manage to “uncover” a great many diagnoses.  In fact, the psychiatric leadership routinely and confidently claim that at any given time about ¼ of the US population has a mental disorder/illness, and that the lifetime prevalence is a staggering 50%.  They remain blind to the fact that these figures are driven by their own interest-invested need to create more “diagnoses” with progressively lower thresholds, and by their members’ equally self-serving need to assign more “diagnoses” in individual cases.

And this is the background against which Judge Johnston felt confident enough to write:

“Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder.”

I truly cannot think of any significant field of human endeavor in which such far-reaching decisions would be made on the basis of such poor evidence.  And bear in mind, Justina’s is by no means an isolated case.

If parents are abusing or neglecting their children – and obviously these things do happen – then some kind of intervention is appropriate.  But interventions of this sort should always be based on clear evidence and with due regard to the rights of the parents and the rights of the child.  But a “diagnosis” of somatic symptom disorder, by its very definition can never reach the standard of clear evidence.  

The Perfect Psychiatrist

On March 19, a new article was posted on Aeon Magazine.  It’s titled A Mad World,  and was written by Joseph Pierre, MD, who works in Log Angeles as a psychiatric practitioner and professor.  Dr. Pierre has authored more than fifty papers, and has received several awards.  He has lectured nationally and internationally, and would, I think, be considered an eminent psychiatrist.  I am grateful to several readers for the link to the article.

The paper is written in a collegial, reassuring manner, but there are some very profound and disturbing implications which I feel ought to be identified and elucidated.

Dr. Pierre opens his discussion with some chatty remarks concerning the reluctance of people to disclose information about themselves to psychiatrists for fear that they might be “.. labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket.”  He then continues:

“Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.”

What he’s saying here, or at least what I think is implied, is that “idiosyncrasies, foibles, and life struggles” are what stands between us and “perfect mental health.”  In other words, idiosyncrasies, foibles, and life struggles are illnesses or symptoms of illnesses.  This, of course, has been psychiatry’s implied message for decades, but it is unusual to see it articulated so clearly.

Dr. Pierre continues:

“As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications.”

So the biggest challenge facing psychiatry today is to rope even more people (“the majority” of the population) into psychiatric “treatment.”  But psychiatry is thwarted in this noble and altruistic challenge because people are fearful that the psychiatric-pharma alliance is on a “mission” to pathologize normality and sell more drugs.  Wherever could we have gotten such a notion?  Perhaps from the inexorable expansion of the DSM catalog?  Perhaps from psychiatry’s long-standing corrupt relationships with pharma?  Perhaps from psychiatry’s willing and active involvement in the fraudulent research?  Perhaps from the pharmaceutical infomercials that posed as, and were avidly accepted by psychiatry as, continuing education?  Perhaps from pharma ads to the general public?  Perhaps from the ghost-writing scandals?  Perhaps from the self-serving fabrication of childhood bipolar disorder by an “eminent” psychiatrist and the consequent widespread prescribing of mind-numbing neurotoxic drugs to children as young as two years for temper tantrums?  Perhaps from the medicalization of bereavement?   Etc.?  So perhaps our fears and concerns with regards to psychiatry’s mission are founded.

Dr. Pierre then gives us a brief historical account of the expansion of psychiatry’s scope including:

“From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.”

It is clear that he approves of this widening of psychiatry’s net and of the general blurring of the distinction between psychiatric “illness” and normality.  One of the putative advantages of this development is that

“… newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses.”

Then:

“Viewed through the lens of the DSM, it is easy to see how extending psychiatry’s helping hand deeper into the population is often interpreted as evidence that psychiatrists think more and more people are mentally ill.”

Actually, it isn’t just interpreted as evidence, it is evidence.  Psychiatrists do indeed promote the notion that more and more people are “mentally ill.”  They have promoted this spurious notion in three ways:  firstly, by increasing the number of their so-called diagnoses, secondly, by progressively lowering the criteria thresholds, and thirdly, by routinely telling their clients that they have chemical imbalances in their brains.

“To many, the idea that it might be normal to have a mental illness sounds oxymoronic at best and conspiratorially threatening at worst. Yet the widening scope of psychiatry has been driven by a belief – on the parts of both mental health consumers and clinicians alike – that psychiatry can help with an increasingly large range of issues.”

So, there it is!  All this time we thought that psychiatry was expanding its scope for self-serving purposes like turf expansion and increased business, when in reality they were just responding dutifully and responsibly to requests for help with an “increasingly large range of issues”!

The fact is that people go to psychiatrists for an increasing range of non-medical human problems, because psychiatrists have developed and promoted the false notions that these problems are illnesses, and that these illnesses are best treated by drugs.  They have also downplayed the adverse effects.  In these endeavors they have been ably assisted by their pharmaceutical allies.  They have also promoted the notion that failure to “treat” these spurious illnesses inevitably leads to dire consequences, particularly in the case of children.  Pharma’s ad campaigns, including ads in psychiatric journals, have been a major driving force in this area for at least the last 40 years.  If psychiatrists had had any qualms about pharma’s excessive rhetoric, shouldn’t they have spoken out?  Shouldn’t they have refused to run the ads?  Is it not reasonable – given the absence of any such protest – to conclude that psychiatry approved of, and was even complicit in this promotion?

To state, at this advanced stage of the proceedings, that psychiatric expansion is simply a reflection of increased confidence on the part of the consumer is at least disingenuous and perhaps blatantly deceptive.

Dr. Pierre continues by telling us that psychiatry’s ” diagnostic creep…becomes more understandable by conceptualizing mental illness, like most things in nature, on a continuum.”  (Note in passing the phrase “like most things in nature,” which conveys the impression that the DSM catalog actually identifies real entities, in the manner, say, of the Periodic Table, when in fact the only ontological status that these “illnesses” have is the fact that they were voted into existence by the APA.)

He then uses the continuum concept to justify the “diagnosing” and drugging of almost anyone.

“For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.”

This is a level of psychiatric spin that I have not encountered before.  Psychiatry has received a good deal of criticism in recent years for expanding their “diagnoses” and for prescribing drugs to more and more people.  There have been some half-hearted and unconvincing rebuttals from psychiatry, but for the most part their response has been:  deny, deflect, and keep your head down till it blows over.  These are the standard tactics of politicians.  But Dr. Pierre has taken us to a new level:  diagnostic expansion and increased drugging are good things.  Imagine a politician confronted with a charge of taking bribes arguing that bribes are a form of economic activity and, as such, should be encouraged in a free market context!

Then Dr. Pierre points out that the DSM, with its fussy little polythetic criteria sets, isn’t really such a big deal.

“The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.”

This is drug-pushing without even the semblance of a medical veneer.  He might as well hang out a shingle:  Whatever ails you, get your drugs here.  I also imagine that, like the street dealer, he gets a lot of repeat customers.

He concedes that he may have to fabricate something to get the insurance company to pay for his services, a practice which incidentally constitutes fraud, but he’s not going to “waste a lot of time” fretting over “such exacting distinctions.”

Then Dr. Pierre treats us to the standard psychiatry-is-just-like-general-medicine claim.

“Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine.”

Why, he asks, if we accept that we can have a wide range of physical illnesses during our lives, are we so reluctant to accept “…that it might also be normal to be psychiatrically ill at various points in our lives?”

And that’s a terrific question.  My answer is:  because “mental illness” is a spurious concept with no explanatory or ontological validity – that the problems embraced by the term are actually not illnesses at all, and that the various “diagnoses” listed in DSM are nothing more than rewording of the presenting problems.  If Dr. Pierre were to spend an hour browsing the anti-psychiatry websites or even reading a few books such as The Myth of The Chemical Cure  by Joanna Moncrieff or Anatomy of An Epidemic by Robert Whitaker, he would get lots of other answers.  But alas, his question was rhetorical.  He already knows the answer.

“The answer seems to be that psychiatric disorders carry a much greater degree of stigma compared with medical conditions.”

There is it – the Jeffrey Lieberman argument: people won’t accept our concepts because of the stigma.  The big, bad, stigma.  It’s got nothing to do with the conceptual flaws, or the damage caused by the “treatments.”  Just that darned stigma! – to which, incidentally, psychiatry’s medicalization drive has been a major contributor, as Angermeyer et al, 2011, have demonstrated so convincingly.

So how can we get rid of stigma?  Well, here again, I could make a few suggestions, but no need.  Dr. Pierre has it all figured out.

“To be less stigmatising, psychiatry must support a continuous model of mental health instead of maintaining an exclusive focus on the mental disorders that make up the DSM.”

In other words:  forget the DSM; forget the diagnoses (who needs them?).  Let’s just acknowledge that everyone can experience suffering and impairment, and offer psychiatric services to all.  Then there’ll be no stigma.  We’ll bump into each other socially as we come in and out of the psychiatrist’s office, and it’ll be:

“What are you in for today?”
“The grandchildren are coming up for the weekend and we thought we could use a little extra Valium.  What about you?”
“Oh, Big Phil has been a bear since we changed over to Daylight Savings Time.  I always need a little Celexa for that.  It takes the edge off, you know.”
“I haven’t been a bear!”
“Yes you have.”
“Really?  Perhaps I should go in and get a little something.”
“Yes, do.  Get some Valium.”

See – no stigma at all.

In fairness to Dr. Pierre, he sounds a note of caution in this regard.

“If the scope of psychiatry widens, will psychiatric medications be vastly overprescribed, as is already claimed with stimulants such as methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)?”

(Note the word “claimed” – but let’s let that go.)

But he reassures us:

“In the end, implementing pharmacotherapy for a given condition requires solid evidence from peer-reviewed research studies. Although by definition the benefit of medications decreases at the healthier end of a mental health continuum (if one isn’t as sick, the degree of improvement will be less), we need not reject all pharmacotherapy at the healthier end of the spectrum, provided medications are safe and effective.”

So, as long as the drugs are “safe and effective,” we can confidently dish them out for “sub-clinical conditions.”  But who determines that the drugs are “safe and effective?”  The same chronically-flawed, short-term, industry-sponsored trials that we have at present.  Every psychiatric drug on the market today is “safe and effective” by that standard.

And here, dear readers, it really goes downhill.

“…the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists.”

“Maximizing wellness”; “enhancing normal functioning”; “cosmetic intervention”;  “make us feel better than normal”?

And then it goes further downhill.

“The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.”

Note the slick juxtaposition of caffeine, on the one hand, with Ritalin and diazepam on the other:  routine aids to daily living.  And what are we to make of likening a pill that could increase IQ by 10 points to the present array of psychiatric drugs?

Dr. Pierre assures us that psychiatrists are just trying to help.

“In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.”

and

“A good psychiatrist draws upon clinical experience to gain empathic understanding of each patient’s story, and then offers a tailored range of interventions to ease the suffering, whether it represents a disorder or is part of normal life.”

On March 22, Psycritic, another psychiatrist, posted a critique of Dr. Pierre’s article.  In this article, psycritic makes some interesting points.  He/she ultimately attributes Dr. Pierre’s enthusiasm for increased drugging to misguided consumerism.  The idea is that while consumerism (sell the customer whatever he wants) is OK with regards to everyday products and services, it can create problems when applied uncritically to medicine.

There is merit to this argument, of course.  But there is another, more fundamental, issue:  that it has been pharma-psychiatry’s objective for decades to expand, without any indication of limits, the use of psychiatric drugs.  Pharma has pursued this objective through advertizing and through the distribution of largesse to psychiatrists.  Psychiatrists, meanwhile, have played their part by creating new “diagnoses,” lowering thresholds for existing diagnoses, making widespread use of their NOS categories, pretending that the drugs are medications, and through active political lobbying, such as the present drive to expand coerced administration of psychiatric drugs.

The reality is that Dr. Pierre is not just an overly-enthusiastic consumerist.  Rather, he is the perfect psychiatrist:  the flag-carrier for all that the APA stands for which is:  that every human problem is the legitimate concern of psychiatry, and for every problem there’s a pill.

 

Psychiatry Misusing the Political Process

On March 27, the US House of Representatives approved by a voice vote with no debate a Medicare bill, HR 4302, Protecting Access to Medicare Act of 2014.  The purpose of the bill is to avoid cutting Medicare payments to physicians, and there was, and is, general agreement on both side of the aisle that the bill needed to pass.

However, tacked onto the bill was a rider which authorized $60 million to expand involuntary outpatient commitment (IOC) in states that already have provision for commitments of this sort.

Involuntary Outpatient Commitment is widely advocated by organized psychiatry.  Their general position is that people who are seriously “mentally ill” are often incapable of making prudent decisions, particularly with regards to the ingestion of neuroleptic drugs.  For this reason, they contend, there needs to be legal compulsion to ensure “treatment” adherence, which usually means forced ingestion of neuroleptic drugs (sometimes in long-lasting injectable form.).

In this debate, psychiatry routinely ignores the truly devastating side effects of these products and the fact that their long-term use is associated with increased neurological damage, deterioration in quality of life, and reduced life expectancy.  They also ignore the well-established fact that forced treatment is simply not effective.

There are also some very obvious civil rights issues involved.

The National Coalition for Mental Health Recovery has taken a strong position on this bill and have posted a press release.

The Senate is due to vote on this bill tomorrow (March 31).  If you oppose this rider to the bill, please ask your Senators to reject this counter-productive amendment.  You can contact your Senators through this link.

The APA has been developing their political lobbying machine in recent years.  On their website you will find the following tabs: Congressional Action Network; Government Relations; State Relations; and Legislative Action Center.  Obviously they’re taking this seriously.  Psychiatry has received a good deal of criticism in recent years, but have consistently refused to take any of this on board.  Instead, they have relied on spin, tawdry PR promotions, and now stealth legislation to promote their expansionist and destructive agenda.

Please contact your Senators today.

Robert Whitaker: Looking Back and Looking Ahead

On March 5, Bruce Levine, PhD, published an interesting article on Mad in America  titled Psychiatry Now Admits It’s Been Wrong in Big Ways – But Can It Change?

Bruce had interviewed Robert Whitaker, and most of the article is the transcript of this interview.

Bruce begins by noting that Robert, in his book Mad in America, had challenged some fundamental tenets of psychiatry, including the validity of its “diagnoses” and the efficacy (especially the long-term efficacy) of its treatments.

Bruce reminds us that Robert initially incurred a good deal of psychiatric wrath in this regard, but also points out that some members of the psychiatric establishment are beginning to express a measure of agreement with these deviations from long-held psychiatric orthodoxy.

Robert was asked if these kinds of developments have rendered him optimistic with regards to the future of psychiatry, and his response is particularly interesting.  He points out that it is obviously a hopeful sign that psychiatry is beginning to recognize at least some of its shortcomings.  But he continues:

“Even as the intellectual foundation for our drug-based paradigm of care is collapsing, starting with the diagnostics, our society’s use of these medications is increasing; the percentage of children and youth being medicated is increasing; and states are expanding their authority to forcibly treat people in outpatient settings with antipsychotics drugs. Disability numbers due to mental illness go up and up, and we don’t see that as reason to change either. History does show that paradigms of psychiatric care can change, but, in a big-picture sense, I don’t know how much is really changing here in the United States.”

And in this regard, Robert is absolutely correct.  He has also pointed us to the very crux of the matter:  psychiatry has never had even the slightest interest in the validity of its concepts.  Psychiatry needed illnesses to establish its dominance of the helping professions arena, and to legitimatize the prescribing of drugs.  So illnesses it created.

Dissent (and there has been a great deal of it over the past 60 years) was routinely stifled, marginalized, and even ridiculed with the help of pharma money.  What Robert has done – and for this he deserves a Pulitzer Prize – is spell out the shortcomings of psychiatry so clearly and so vigorously that the psychiatric leadership can no longer pretend not to hear.  But there is, I suggest, nothing in the attitude of organized psychiatry to indicate any interest in fundamental change.

Jeffrey Lieberman, MD, President of the APA, in his fortnightly article in Psychiatric News, continues to insist that psychiatric diagnoses reflect real illness and that psychiatry should not only maintain its present level of activity, but should actually widen its net to embrace those populations that are “underserved,” as well as those who are “at risk.”

DSM-5 (May 2013) actually contains the phrase

“…DSM, like other medical disease classifications…” (p 5) [Emphasis added]

The psychiatric leadership may well have decided to stop bashing Robert.  But this in my view does not reflect any kind of honest re-appraisal of their philosophy or their practices.  For psychiatry, today, as for the past 60 years, all significant problems of thinking, feeling, and/or behaving are illnesses, best treated by psychiatrists using neurotoxic drugs and electrically-induced seizures.  The only difference at this time is that they’re keeping their heads down, hoping, in politician style, that the present hue and cry will die down, that the pharma companies will re-start the pseudo-research gravy train, and that they can continue with their mission of drugging and disempowering an ever-increasing number of people.

There are, it has to be acknowledged, a very small number of psychiatrists who recognize the truth about psychiatry, and they are speaking out courageously and honestly.  But the great majority of psychiatrists, including the leadership, are still marching in lock-step to the biological illness drum. They no longer have the gall to say “just like diabetes,” but the general idea is still the same.  The protests, including those from the survivors, are being ignored, the drugs are still flowing like candy, and politicians are being lobbied for legislative and financial support.

We still have a lot of work to do.

Benzodiazepines: Dangerous Drugs

On February 25, Kristina Fiore published an article on MedPage today.  It’s titled Killing Pain: Xanax Tops Charts

The article is based on a study conducted by Jann M et al, and published in the February 2014 issue of the Journal of Pharmacy Practice.  The study is titled Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics.  Here’s a quote:

“During 2003 to 2009, the 2 prescriptions drugs with the highest increase in death rates were oxycodone 264.6% and alprazolam 233.8%. Therefore, benzodiazepines have a significant impact on prescription drug unintentional overdoses second only to the opioid analgesics. The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression.”

Alprazolam is a benzodiazepine.  It was marketed as Xanax in 1981, and has been available in generic form since 1993.  It is used by psychiatrists as an anti-anxiety agent.

When the benzodiazepines were first introduced, it was widely claimed, both by psychiatrists and by pharma, that they were non-addictive.  This claim was subsequently abandoned in the face of overwhelming evidence to the contrary, and the addictive potential of these products is now recognized and generally accepted.  Incidentally, you can find some interesting history on the promotion of tranquilizers, including benzos, on a Medpage timeline published last month.  The timeline presents ads gathered from the New England Journal of Medicine and from the Journal of the American Medical Association.  It’s tawdry stuff.  Thanks to Laura Delano for the link.

Back to Ms. Fiore’s article.

“When a patient comes in with complaints about anxiety, it’s easy to write a prescription for Xanax, Jann said.  Like other benzodiazepines, it’s cheap and it’s perceived to be safe.”

She also quotes Daniel Carlat, MD, professor of psychiatry at Tufts:

“Xanax really is a tried and true medication…When patients take it, they feel its effect quickly.”

 And

 “It also goes to work fast, which may be a reason why patients show a preference for it…”

 Miss Fiore has also interviewed Allen Frances, MD, former psychiatric chair at Duke and architect of DSM-IV:

“And the drug is an easy solution for primary care doctors who are pressed for time, said Allen Frances, MD, a professor emeritus and former chair of psychiatry at Duke University.

Indeed, the majority of benzodiazepine prescriptions in 2013 were written by family practice or internal medicine doctors, totaling some 44 million prescriptions. That’s vastly more than the 13 million written by psychiatrists.

Frances said that if the FDA were to conduct a thorough review of Xanax, it might not be so widely prescribed.

‘The effects of Xanax are much more subtle and dangerous,’ he said. ‘In combination it can be deadly, and for many people it creates an addiction problem that’s worse than the original condition.’

‘I think if there was a careful review of its risks and benefits, it would be taken off the market,’ he added, ‘or it would at least have much more restricted use.'”

Dr. Frances has reinvented himself in recent years as an outspoken critic of DSM-5 and of psychiatric excesses generally.  His points are usually cogent and well made, but he remains unreceptive to the fact that his own brainchild, DSM-IV, was an integral step in psychiatry’s spurious and self-serving medicalization of non-medical problems.

The fact is that anxiety is not an illness, and drugs that dissipate anxiety are not medications – they are drugs.

Benzodiazepines have a legitimate use in general medicine, and in that context are indeed medicines in the proper sense of the term.  But when prescribed for anxiety on a routine, daily basis, they are drugs.  They fall into the class of drugs that addictionologists call sedative-hypnotics, and are similar in their general effects to alcohol and opiates.  I worked in the chemical dependency field in the late 80’s – early 90’s, and even then we were admitting large numbers of people addicted to benzos.  It was, and is, an extremely difficult addiction to overcome.  Withdrawals are typically difficult, protracted, and sometimes dangerous.  Monica’s Cassani’s website Beyond Meds goes into this in great detail.

Dr. Frances makes the point – undoubtedly true – that general practitioners prescribe more benzodiazepines than psychiatrists.  This is a common cry from psychiatry when confronted with the damage that their products are causing.  But the argument is specious, because no practitioners could prescribe these drugs as a daily “treatment” for anxiety if psychiatry had not, in the first place, promoted the false message that anxiety is an illness.  No doctor could prescribe these products for these purposes if psychiatry had not invented, packaged, and sold their various anxiety “diagnoses.”  When psychiatry embarked on its great mission to medicalize every conceivable human problem, they basically drove the bus off the cliff .  Mental health today is still in a state of uncontrolled free fall.  And every time we hit an outcropping, or the bus turns end over end, psychiatry says: “Oh dear!  How did that happen?”  Well it happened because organized psychiatry put money and prestige above intellectual and moral integrity.  The damage this has done, and continues to do, is beyond reckoning. 

Psychiatry has damaged and killed human beings who came to them for help.  They have routinely disempowered people, and have spuriously equated all human distress to their confidently-touted, but fictitious, chemical imbalances, and, more recently to the twitching of aberrant neural circuits.  They have arrogantly promoted themselves as the arbiters of normalcy and the healers of emotional pain.  They have systematically undermined the notion of self-improvement through effort, and through natural social support networks.  They have enslaved millions to their toxic psychotropic chemicals.  And we haven’t hit bottom yet.

Anxiety is not an illness.  It is a normal human response to ambiguous or potentially challenging or dangerous situations.  I’ve written more on this in my post Anxiety Disorders.  Modern life is fraught with anxiety-arousing situations.    If psychiatry had had the slightest interest in truly helping people, it would have focused on this reality, and developed genuinely helpful concepts and practices in this area.  But there isn’t much money in that.

So instead, intoxicated by its customary delusion of infallibility, it did what it always does:  issued the self-serving decree that anxiety is an illness best treated by “medications.”

Dr. Frances is correct:  benzodiazepines should be taken off the market – not only because they are dangerous, but also because the notion of washing away people’s anxieties and concerns in a drug-induced haze of semi-euphoria is fundamentally disempowering, and makes a mockery of the practice of medicine.  The only possible honest response from a physician who is asked to treat anxiety, is to point out that anxiety is not a medical matter.

People who take these drugs as a routine measure to insulate themselves from life’s multi-variate challenges and vicissitudes are not medicated.  They are stoned.

And the great irony here is that everybody knows this.  The individuals know it; their family members know it; their friends and co-workers know it; the psychiatrists themselves know it.  And the street pushers who obtain benzos illegally know it.

But the great fiction has to be maintained.  Here’s a quote from Benzodiazepines:  A versatile clinical tool, by Bostwick et al in Current Psychiatry, April 2012

“Since the discovery of chlordiazepoxide [Librium] in the 1950s, benzodiazepines have revolutionized the treatment of anxiety and insomnia, largely because of their improved safety profile compared with barbiturates, formerly the preferred sedative-hypnotic.”

And psychiatry and pharma go on making a killing.  According to the Kristina Fiore article mentioned earlier, there were 94 million prescriptions for benzos written in the US in 2013.  Psychiatry is out of control.

Justina Pelletier and Boston Children’s Hospital

Justina Pelletier is the 15-year-old girl who is at the center of a dispute between her parents and the Psychiatry Department at Boston Children’s Hospital.

Justina, who lived with her parents in Connecticut, had been diagnosed with mitochondrial disease, a rare and debilitating illness, and had been receiving treatment for this from Mark Korson, MD, Chief of Metabolism Services at Tufts Medical Center in Boston.

In February of last year, Justina’s parents took her to Boston Children’s Hospital with flu-like symptoms.  Dr. Korson had recommended an admission to Boston Children’s so that Justina could be seen by Alex Flores, MD, a gastrointestinal specialist who had recently transferred from Tufts to BCH.

But instead, Justina’s care was taken over by the psychiatry department.  She was “diagnosed” with somatoform disorder (“it’s-all-in-your-head”), and BCH reported the parents to the state of Massachusetts for medical child abuse.  The complaint was taken by the Department of Children and Families (DCF), and within 24 hours Judge Joseph Johnston awarded custody of Justina to the Massachusetts DCF, and ruled that she had to stay at BCH.

The parents continued to press for Justina’s release from BCH, but were hampered in these efforts by a gag order that Judge Johnston had imposed.

In January of 2014, having spent almost a year in psychiatric care at BCH (nine months of which were in a locked ward), Justina was transferred to the Wayside Youth and Family Support Network in Framingham, Massachusetts.  She was still in the custody of the DCF, and still under the care of psychiatrists at Boston’s Children’s hospital.  In February of 2014, Justina’s father, Lou Pelletier, alarmed at the deterioration in his daughter’s medical condition, decided to break the gag order, and go public, despite the risk of imprisonment.  There was a huge outcry, and Massachusetts child protective services stated on February 28, 2014, that they are actively working to return Justina to Connecticut and the care of Tufts.

“The timetable for the shift of the teenager to her home state has not been set, and it is unclear just how much the Massachusetts Department of Children and Families is retreating from the girl’s case. But Loftus [DCF spokesperson] said child-protection officials from both states, the juvenile judge handling the case, and lawyers for the parents are actively working on identifying a new placement in Connecticut. He would not say what places are under consideration, but in cases like this, the child could be returned back to her home, or placed in a foster home or a residential treatment facility.

If she were to live at her family’s home in West Hartford, Conn., child-protection officials in that state, who would likely oversee the case, would likely demand that the girl receive services at home or that she attend a day program.”

Because of the gag order, which was in place since November 17, 2013, and the official secrecy that normally attends these matters, it’s difficult to establish all the facts.  But the gist of the conflict seems to be that the psychiatrists at BCH disputed the diagnosis of mitochondrial disease.  (In fact, there are indications that they may even have disputed whether such a disease even exists – an extraordinary accusation coming from psychiatry!)  They also, apparently, formed the belief that the parents were dysfunctionally invested in the notion that Justina was gravely ill, and were subjecting her to needless medicines and treatments.  During the eleven months she was at BCH, the psychiatrists placed very strict and stringent limits on how much contact the teenager could have with her family.  There’s a copy of a January 8, 2014, letter here from Kathleen Higgins, RN, a former BCH employee, to the DCF Commission.  The letter provides a great deal of insightful background.

The parents protested vigorously that Justina had been taken off the medicines for mitochondrial disease, and they stated that her physical condition had deteriorated markedly during her stay at BCH.

DISCUSSION

Somatoform disorder is a DSM-IV term.  It refers to a group of psychiatric “diagnoses,” the common feature of which is “…the presence of physical symptoms that suggest a general medical condition…and are not fully explained by a general medical condition…”  (DSM-IV, p 445).  In addition, “…there is no diagnosable general medical condition to fully account for the physical symptoms.” (ibid)  Like all psychiatric “diagnoses,” it has no explanatory value and is nothing more than a destructive and unreliably applied label.

So essentially what’s happened here is that Dr. Korson, a pediatrician who is board-certified in Clinical Biochemical Genetics, an associate professor at Tufts University School of Medicine, and a specialist in mitochondrial diseases, has been treating Justina for about three years for mitochondrial disease.  (According to the site MitoAction, “Dr. Korson is universally recognized as an expert in clinical practice for mitochondrial patients.”)  He sends her to BCH for a gastrointestinal consult with Dr. Flores.  And within 24 hours, the psychiatry department hijacks her, rejects the mitochondrial disease diagnosis, substitutes a “diagnosis” of its own, files a medical abuse report with DCF, and supports a DCF petition to have Justina made a ward of the state.  Prior to all this, Justina had no mental health history of any kind.

As soon as they realized what was happening, the parents sought to remove Justina from BCH – but when the teenager became a ward of the state, that door was closed, and the judge ordered that Justina be kept at BCH.

Justina’s case has focused a great deal of attention on these matters generally.  One of the points that has emerged fairly clearly is that BCH’s procedure for pursuing a commitment of this kind is a well-oiled machine.  The BCH physicians and staff on the one hand, and the DCF staff on the other, work closely to prepare their cases, and the courts are usually cooperative.  Psychiatric evidence is afforded a high measure of credibility and deference, and, as in this case, the child is routinely ordered to remain at BCH.

The problem with all of this is that BCH stands to make a great deal of money on every child that is court-ordered to remain in their care.  The conflict of interest is glaring.  It’s like a judge routinely sending convicted criminals to a private prison that he himself happens to own.  The difference is that any judge who engaged in activity of this sort would be looking at criminal charges and disbarment.  But in psychiatry, this sort of thing is common.

The matter is particularly compelling in that reports are emerging that BCH tends to pursue these kinds of court orders in cases where the family has “good insurance.”  Justina was kept at BCH for eleven months.  I have seen no reports as to the size of the bill, but I’m sure it wasn’t trivial.

BCH AND HARVARD

David R. DeMaso, MD, is the head of psychiatry at BCH.  He is also a professor at Harvard, and is a member of Harvard’s Psychiatry Department Executive Committee. He is evidently highly regarded at the University, and has his own Harvard Catalyst page.  There’s a tab on this page labeled “Similar People,” and one of the people listed as “similar” to Dr. DeMaso is our old friend Joseph Biederman, MD, the eminent inventor of pediatric bipolar disorder.  This is the bogus diagnosis that legitimized the prescribing of neuroleptic drugs to children as young as two years old for temper tantrums.  Even some psychiatrists spoke out against this spurious and destructive activity, but the practice continues.  The fact that Dr. DeMaso would allow Dr. Biederman’s name to remain on his Similar People tab seems noteworthy.  There is also a “connections”  page on Harvard Catalyst, listing three publications co-authored by Dr. DeMaso and Dr. Biederman.

Dr. Biederman is on record as promising Johnson & Johnson a positive result for their drug Risperdal if they would fund his study.  Why would any reputable physician allow someone like that to remain on his “Similar People” tab?

I did a PubMed search to see if there were other links between BCH psychiatrists and Joseph Biederman.  In addition to the DeMaso publications, I discovered papers co-authored by Joseph Biederman and at least two other members of the BCH Department of Psychiatry “Leadership Team:”  Joseph Gonzalez-Heydrich, MD (7 articles, as recent at 2012); and Deborah Waber, MD (3 articles, as recent at 2012).

PUBLIC OUTCRY

None of Justina’s story would have come to light had there not been an extensive and vigorous public outcry.  This in turn would not have happened if Justina’s father, Lou, had not breached the court’s gag order.  The fact that our courts can effectively prohibit a parent, on pain of imprisonment, from speaking out against his child’s enforced psychiatric treatment ought to be a huge concern.  Our legislative and legal systems have been hoodwinked by psychiatry for too long.  The right to free speech is our most fundamental political freedom.  The fact that a state court would so cavalierly suspend such a right to promote the agenda of BCH’s psychiatry department suggests a measure of partiality on the part of the court in an area where the child’s welfare ought to be the paramount consideration.  There had never been the slightest indication that Justina’s parents had been abusing or neglecting her.  In fact, they brought her to BCH on the advice of the child’s physician to get help for the flu-like symptoms.  By any conventional standards, they were being dutiful and attendant.  The gag order was clearly an attempt to prevent them from drawing adverse publicity to BCH’s psychiatry department.  Courts are supposed to be impartial.  Why would the court in this case have assumed that the psychiatry department’s motives were benign, that its “diagnoses” were valid and accurate, and that its practices were judicious and efficacious?  Why did the court not recognize the financial conflict of interest when it ordered that Justina be kept involuntarily in the locked psychiatric ward at BCH?

BCH’s psychiatrists kept Justina in a locked psychiatric ward for nine months.  Apparently it never occurred to them that they might have made an error, or that they had acted too hastily. Psychiatry seldom engages in anything even remotely akin to critical self-scrutiny.  They have resisted the parents’ protests at every step of the way, and have been backed throughout by the court.  It is only because of the public outrage that the facts are emerging.  Massachusetts’ Department of Public Health has called for a full investigation of the matter.  One can readily imagine the kinds of pressures that will be brought to bear to whitewash the entire affair.  Let us all, individually and collectively, do what we can to ensure that this does not happen.

ADHD: Are We Helping Or Harming?

In November 2013, the British Medical Journal published Attention-deficit/hyperactivity disorder: are we helping or harming? by Rae Thomas, PhD, Psychologist, Australia; Geoffrey K. Mitchell, MB BS, FRACGP, PhD, Professor of General Practice, Australia; and Laura Batstra, PhD, Psychologist, Netherlands.  The article is part of a series on the dangers of overdiagnosis.

Here are some quotes:

“Prevalence and prescribing rates for attention-deficit/hyperactivity disorder (ADHD) have risen steeply over the past decade, partly in response to concerns about underdiagnosis and undertreatment.”

“…prescribing rates for commonly used drugs such as dexamfetamine, methylphenidate, and atomoxetine for children diagnosed with ADHD have increased.”

“DSM-5 widens the definition of ADHD by expanding behavioural descriptions to include more examples and increasing the maximum age of symptom onset from 7 to 12 years.”

“Among the work group advisers of DSM-5 for ADHD and disruptive behaviour disorders, 78% disclosed links to drug companies as a potential financial conflict of interest.”

“The main medications for ADHD are methylphenidates and amfetamines, which can cause adverse reactions such as weight loss, hepatotoxicity, and suicide ideation, and in the short term may suppress pubertal growth.”

“A diagnostic label is value laden and has the potential to cause harm and, paradoxically, increase mental health problems.”

SUMMARY

This is an interesting and important article.  The authors emphasize the factors that are driving the increased “prevalence” and the consequent potential damage, particularly in what they call mild and moderate cases.

Unfortunately, although they don’t describe ADHD as an illness, they do appear to accept a medical perspective, or at least a need for medical intervention, in severe cases.  If the problems persist after “minimal intervention” with parents and some “brief …counselling,” they recommend that the child be referred to “a developmental pediatrician or psychiatrist for definite diagnosis and treatment”.

This general theme – that the condition known as ADHD is a valid medical entity that is simply being overused – is becoming quite common.  It was the primary thread in Dr. Lieberman’s latest article, and is being widely promoted in an attempt to rescue the illness concept from collapsing under its own weight.

But in reality, there is no more reason to conceptualize severe inattention/impulsivity as an illness, than mild inattention/impulsivity. 

Nevertheless, the article is useful.  It is certainly a step in the right direction, and provides a long list of references.  With regards to the illness concept, my guess is that the wording of the article represents a compromise.  Dr. Batstra is quoted elsewhere as saying that “It is a fallacy to regard ADHD as an illness.”  Dr. Thomas in Moving the diagnostic goalposts: medicalizing ADHD, states:  “I believe that attention deficit hyperactivity disorder is a real disorder; I also believe it’s too frequently diagnosed and over-treated.”  Dr. Mitchell’s position is harder to assess, but from the wording of some articles of which he was a co-author, it seems possible that he conceptualizes ADHD as an illness.

For the record, and to guard against misunderstanding, it is my position that the condition known as ADHD is a loose cluster of vaguely-defined problem behaviors, most of which can be conceptualized as a failure on the part of the child to acquire age-appropriate habits in the areas of discipline, self-control, and social interaction.  It is not an illness in any meaningful sense of the term.