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.

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