Cognition & Reality

Sunday, 24 April 2011

Disease, Disorder, Distraction

Responsible scientists who are familiar with the research but want to preserve the disease concept of alcoholism have had to redefine their terms. They define “disease” as whatever doctors choose to call a disease (Jellinek, 1960)! The point of using the word, they acknowledge, is “social” rather than medical. There is a lack of consistent self-control that leads to harmful consequences (Vaillant, 1990). Of course such sweeping uses of the term make almost every human and social problem into a “disease.”

In the above passage, from a book chapter published over 20 years ago, Herbert Fingarette prefigured the current obsession with attributing any troubling behavior to an underlying disease. The extension of medicine into areas where it does not belong, because its methods do not apply, is an insidious ongoing process. We have not only given doctors great power within the legal domain, but we have also permitted the ideology called “medical science” to dominate the cultural definition of many types of behavior.

Sadness and worry are now perceived as symptoms of an underlying disease, although they could result from a wide range of potential causes. To be in a down mood is the natural response to various circumstances, such as a bad marriage or financial difficulties; and events, such as the loss of a job or loved one. As the beginning of this piece from The Guardian suggests, however, the medical community and the pharmaceutical industry have succeeded in redefining a psychiatric condition called “depression” as a common disorder. Because it is presumed to have an underlying physiological cause, a critical feature of this newly redefined disorder is that it can be addressed with certain expensive medications.

Accordingly, the official numbers indicate that 9% of the US population count as “depressed,” with 3.4% meeting the criteria for Major Depressive Disorder, while doctors write millions of prescriptions for antidepressants yearly, at a rate that continues to accelerate. From one perspective, these figures raise questions about a society with a tenth of its members bummed out, some seriously bummed out, many of them dependent on daily doses of drugs having limited efficacy and unknown long-term effects. From another perspective, the same figures raise questions about what counts as a mental disease or disorder such that so many people suffer from such conditions.

Our society had become addicted to medicalizing social, moral and spiritual problems. As Fingarette predicted, many troubling behaviors have been reconceived as disease states. Doing so puts money in the pockets of pharmaceutical companies and physicians, while it reassures members of both the medical profession and the general public. Insurance companies and government agencies like it, too, because the treatment of medical disorders usually involves medication and other courses of treatment that are much less expensive than traditional psychotherapy, with its emphasis on developmental issues.

First of all, there are “food addiction,” and “sex addiction,” new names for otherwise normal activities that have reached an unacceptable level of excess. Although eating too much can be injurious to one’s health,and reckless promiscuity can wreak havoc, putting these problems into a category with dependence on intoxicants places them within the same disease-oriented framework. As discussed in a previous post, conceptualizing substance abuse as resulting from “disease” is misleading as a guide to treatment and unjustified by empirical evidence, and the same is true, of course, for destructive patterns of behavior to which the addiction metaphor has been extended. Nevertheless, there are many intensive, expensive treatment programs, modeled on programs for substance abuse, dedicated to treating overeating and promiscuity.

The emergence of Asperger syndrome as a diagnosis shows that the redefinition of human behavior as disease does not stop with sadness, overeating, and fucking too much (however much that is). Most people realize that this “syndrome” is nothing more or less than “nerdiness,” as it was called before it became a disease. A look at the diagnostic criteria for Asperger’s illuminates its shaky foundation. A child need only meet two diagnostic criteria by exhibiting “impaired social interaction,” and “repetitive and stereotyped patterns of behavior”; other criteria, such as having “inadequate relationships,” or “impaired nonverbal communication,”among others, belong in the “Maybe” category. Treatment for this “syndrome” is a joke, consisting mainly of medications insurance companies will pay for, and therapeutic modalities that, by their nature, are limited in duration: physical therapy, occupational therapy, cognitive behavioral therapy, social skills training, and parenting classes. It need hardly be said that none of these has yielded reliable improvement of the identified problems. Nerdy children may suffer some pain as a result of their behavior, although the very nature of the “syndrome” presupposes that they don’t notice the inadequacy of their relationships. For sure, children who fit the criteria for Asperger’s are annoying, and they can grow into adults with horrible manners, which may explain the amount of attention this “disorder” has received from physicians and psychologists.

Attention deficit hyperactivity disorder (ADHD) is another instance of the “diseasing” of behavior that is deemed to be troubling and disruptive. The controversy over ADHD is so old and so fraught with emotion that there is no point in revisiting it here. Suffice it to say that a recent study, conducted under the auspices of the National Institutes of Health, found that, despite initial improvement, children treated for ADHD through a variety of different recognized modalities, either singly or in combination, fare far worse than children who have not been diagnosed with ADHD. The children received the best treatment the medical establishment can offer, including advanced medications, for at least 14 months, and some were still receiving treatment years later, when they were assessed for their school performance and many other variables relevant to social  and psychological adjustment. Nevertheless, as the results summarized in this table show, they compared unfavorably with comparison subjects on almost every measure chosen by the investigators, who undoubtedly believed in the efficacy of treatment. If ADHD is a disorder with physiological substrates that reflect a genetic disposition, as has long been claimed, “medical science” has not succeeded in discovering how to treat it.

Much the same can be said about the medical approach to the other problems surveyed here. Recidivism by alcoholics and drug addicts who have gone through draconian rehabilitation regimes is notorious. Depression remains a significant problem, as one can tell from the number of commercials one sees for antidepressants. No one is suggesting that there is a reliable treatment for Asperger’s or ADHD. In spite of this abysmal record, physicians continue to operate under the questionable assumption that these conditions represent underlying, circumscribed causes, and continue to treat these conditions as if they know how to ameliorate their effects.

Saturday, 13 November 2010

Scientific Authoritarianism

A genuine grasp of current genetics research would take years to acquire and involve the rigors of a postgraduate education. The same is true of any branch of physiology. An ordinary citizen, even one who is otherwise well-educated, cannot hope to bring any level of technical expertise to evaluating claims about the genetics of mental disorders. As I explained in yesterday’s post, even doctors are at sea when it comes to this topic, although they may not realize it. Therefore, belief in those claims depends, at least in part, on faith and obedience.

That is why, rather than supporting explanations of psychoemotional difficulties based on individual experience, which would ostensibly be more consistent with an American emphasis on individual responsibility, our society has gravitated toward explaining aberrant behavior with reference to physiological, “disease” processes beyond a person’s control.

Thursday, 11 November 2010

DSM-IV & Reality

I found the following paragraph in the course of my reading about “chemical imbalances.” I couldn’t have said it better: The diagnostic enterprise in psychiatry has transformed from nosological exploration into reifying patterns of psychoemotional distress, as if patients’ symptoms represent “real” diseases underneath. It is similar to the “computer metaphor” in cognitive psychology, which went by barely perceptible steps from cute heuristic into actively characterizing the mind as a computer, until ostensibly intelligent people were talking seriously about “storage,’ “retrieval,” “programming,” etc., as if they are authentic features of cognition.

On a still more fundamental level the use being made of the DSM-III and IV model of illness is at issue. DSM-II, perhaps out of respect for the underlying psychodynamics believed to be behind patient’s symptoms, tended to be loose about how to label patients. What was going on inside was more important. Beginning with DSM-III the decision to cluster symptoms into operational definitions that were consensually agreed upon was a proper step in trying to use scientific models. We were asked to buy into the principle, that regardless of theories about causality, there would be an agreed upon name for the collection of observed symptoms. But it has all too often deteriorated into a Platonic essence model, that is, a belief that there is a “real” version of the illness and actual illnesses are imperfect derivatives. If we truly understood etiology and pathogenesis this approach would be wonderful. It would mean we had arrived at the promised land. But short of this, DSM-IV can actually hinder therapeutic perspectives and treatment approaches. From “A Reevaluation of the Relationship between Psychiatric Diagnosis and Chemical Imbalances,” by Simon Sobo, M.D.

Thursday, 21 October 2010

“Depression” Makes Me Sad

I’ve discussed my problems with the term “depression” in  a post from a couple of months ago. I’m returning to this topic because the term “depression” encapsulates so many of the misconceptions that plague the current public discussion of emotional and psychological problems. I want to emphasize that the term “depression” itself exemplifies the dangerous imperialism of medical “science.”

A woman whose husband beats her, for example, might very well meet the DSM criteria for depression. If medical doctors knew what to look for, which they do not, her brain might even manifest biochemical signs of depression, the famous “chemical imbalances.” What she really suffers from, however, is an imbalance of strength with her spouse,  a lifetime of  social conditioning that keeps her in her marriage, and  the lack  of resources that would permit her to leave.

The current propaganda about depression, because there is no actual evidence for the “chemical imbalances” that supposedly underlie it, invariably describe depression as “associated” with changes in neurotransmitters. As I’ve said before, that skates past the problem of determining the relationship between supposed brain states, which can be seen only through a glass darkly, and emotional states that are all too obvious. In the absence of actual biochemical evidence, the argument invariably put forth to defend the “chemical imbalances” claim is that some drugs affect mood in some people. As is true of so much of the “logic” put forth by believers, this argument confuses causes with cures. Aspirin ameliorates headaches. Does that mean that it addresses an acetylsalicylic acid imbalance in the brain or body? I suppose that you could say that if  I received morphine for pain, the medication has addressed an “endorphin imbalance” in my body, although the real physical insult that caused the pain has nothing to do with the biochemistry of pain transmission.

Monday, 16 August 2010

Medics And Morality

Filed under: Chemical Imbalance,Diagnosis,DSM,Medical Morality,Sex & Love — drtone @ 1:45 pm

A tragic trend in our society has given to physicians a large hand in shaping attitudes toward moral questions. For many years, our society has gravitated toward explaining what were once considered moral “failings” as medical disorders. Drunkenness, excessive gambling and destructive promiscuity are all  “addictions” treatable as diseases, through a combination of medication and highly structured behavioral programming. Insanity and emotional problems no longer result from circumstances caused by bad parents, but from chemical imbalances determined by the bad genes. This  effort to mold society according to a medical model is making doctors the arbiters of moral questions, although as a group they are singularly unsuited to the task.

The process of becoming a physician selects against the  reflection  and awareness one might want in a moral philosopher. The notoriously tough competition for entrance into medical school tends to go to the hardest working students rather than to the most creative. There is in a medical education that consciously reduces issues of life and death to CT scams and test results little to attract those most interested in the deepest questions. Although doctors like to style themselves as “scientists,”training in anatomy, applied physiology and clinical practice leave no room for the years of experience required to develop as a researcher. Although there are no hard and fast rules governing who enters the medical profession, the qualities that make a good doctor, a highly analytical mind, tremendous attention to detail,  ice water in the veins, are rarely found in combination with deep reflection and great sensitivity.

The upshot is that doctors consistently deliver simplistic solutions to life’s problems. These solutions tend to credit numbers over ideas and sensibleness over sensuality. In my own life, I’ve had to face the implications of an elevated PSA score, which is a warning sign of prostate cancer. Society’s answer, the medical profession’s answer, to the specter of prostate cancer is radical treatment that as often as not cuts literally and figuratively into one’s sex life. The implicit message is, “Only a fool would question giving up having erections as the cost of living cancer free,” although it is widely understood that prostate cancer is vastly overtreated, such that many men have needlessly had their sex lives shortened. We live in America, where sexual satisfaction is forever at the bottom of the list. In any case, human desire does not fit into the physician’s calculus.

Thursday, 22 July 2010

The Danger of Diagnosis

Filed under: Diagnosis,DSM,Uncategorized — drtone @ 12:21 pm
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A psychologist who must send a report to an insurance company in order to obtain reimbursement for treating a patient is in a difficult situation, however routine such reports may be. He or she must supply a “diagnostic code” based on the Diagnostic and Statistical Manual, published by the American Psychiatric Association, soon to appear in a fully-revised fifth edition. Although it is not a legal document or itself the result of legislative action, the DSM has attained a quasi-legal status. Technically, for a psychologist to supply an erroneous DSM diagnostic code on an insurance form is a violation of standards that are established by law in California and other states.

DSM diagnosis, reflecting psychiatry as a branch of medicine, presupposes that there is an underlying factor similar from one patient to another that produces a set of observable symptoms, as might be the case for an infection. Never mind that such is manifestly not the case, even where a symptom picture is similar from one patient to another. A psychiatric diagnosis is, therefore, a descriptive box that fits no one. It does little, if anything, to support treatment.

Being forced to produce a diagnosis, however, cannot help but color a psychologist’s perception of a patient, no matter how much or how little faith the psychologist has in the diagnostic procedure. The psychologist treats the patient while being paid to treat his or her disorder,  a fine kettle of fish, good for no one…except the insurance company.

Note: A few days after I posted this, I found this post by Peter Breggin, which covers the same topic in a manner consistent with my point of view, but from a different angle.

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