In the summer of 2001 I became very ill. The symptoms were exhaustion and mild nosebleeds. I went to three different practitioners, but they all were dismissive of my concerns, assured me that I was in good health, and sent me on my way. On August 8th of that year I was admitted to the hospital in Greeley, Colorado with complete kidney failure. The nephrologist at the hospital gave me the diagnosis that had eluded the earlier doctors: Wegener’s Granulomatosis – a rare autoimmune disease that attacks lungs, kidneys, and airways. I have been on dialysis every since.
The reason I tell this story is to illustrate the meaning and significance of a medical diagnosis. In my case there were certain signs and symptoms. For instance, I told the doctors that I was tired and that this was not characteristic of me. I told them of the nosebleeds. And they could see that I was dragging. By the time I got to the second doctor, I was also vomiting and having difficulty sleeping.
Now the point is that until I got to the hospital in Greeley, there had been no diagnosis. One doctor said: “maybe you’ve got the flu?” But it didn’t feel like flu, and this tentative diagnosis wasn’t very convincing.
When we ask for a diagnosis we are asking for an explanation. So if you‘re very tired and you’re spitting up dreadful-looking phlegm, a doctor might diagnose pneumonia and would be able to substantiate this diagnosis through observation and lab tests. And – and this is critical – he would be able to show a clear causal link between the pathology and the symptoms.
In my case, the diagnosis of Wegener’s Granulomatosis explained the exhaustion (increased toxicity due to kidney failure) and the nosebleeds (Wegener’s Granulomatosis is believed to be triggered by an airborne pathogen and so the immune system becomes particularly active in this area).
The key is explanation. A good diagnosis pinpoints the pathology, explains the symptoms, and directs treatment. This is the model that has lifted Western medicine out of the charlatanistic quackery that predominated prior to about 1880. Modern medicine is remarkably successful precisely because it is based on an understanding of the pathology involved. Now obviously, as in my case, it sometimes isn’t easy to make a diagnosis, but in the vast majority of cases, people seeking medical help receive an accurate diagnosis early in the process, and this diagnosis guides and directs treatment, usually with a good deal of success.
Now let’s consider the so-called mental health diagnoses. Take the condition known as Attention Deficit Hyperactivity Disorder. The American Psychiatric Association says that this is a mental illness. In other words, ADHD is a diagnosis. And they list the symptoms of this diagnosis. I have reproduced these so-called symptoms in an earlier post, and it’s not necessary to reproduce them here, but here are three fairly typical items from the list:
- often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
- often leaves seat in classroom or in other situations in which remaining seated is expected.
- often runs about or climbs excessively in situations in which it is inappropriate…
Now what the APA have done is this: they have asserted that these are the symptoms of the mental illness that they call ADHD. Now if this means anything, it should mean that ADHD is the explanation of these misbehaviors. And this is precisely how the so-called diagnosis is used in practice. When a parent asks why his child is so unruly and undisciplined, the reply he is given is: because he has ADHD. The putative mental illness is routinely proffered as the explanation – as the underlying pathology which explains why the child is so misbehaved.
But in fact if one examines the matter further, one finds no substance to this so-called diagnosis. ADHD is nothing more than a name for this kind of misbehavior. The acid test here is the question: how do you know he has ADHD? And the only possible answer is: because he is so unruly and undisciplined. The only evidence for the so-called diagnosis is the very behavior it is supposed to explain.
Real diagnoses involve real pathology that one can identify, test for, and hopefully ameliorate. Wegener’s Granulomatosis, for instance is a real disease. And it is recognized as a diagnosis today because Dr. Wegener, a research pathologist working in Germany in the 1930’s, noticed certain microscopic anomalies in corpses he was dissecting. He began to tie these anomalies with symptoms observed before the individuals had died. His work was interrupted by the war, but after the war he refined his observations, and the diagnosis was firmly established. At first there was no treatment for WG – it was effectively a death sentence – but gradually drugs became available, and today the disease is eminently treatable, though because of its rarity, the diagnosis is often missed (as in my case).
In contrast, consider the so-called diagnosis ADHD. Prior to 1950 this diagnosis did not exist. Today it is deeply embedded in psychiatric practice, and indeed in our collective consciousness. This change occurred – not because of a discovery – but because an APA committee decided that ADHD is an illness. As preposterous as this sounds, it is exactly what has happened. In the six decades from 1950 to the present, the primary business of the APA has been redefining the ordinary everyday problems of living (that our ancestors tackled using ordinary time-worn tactics) as mental illnesses. And this has been done in collaboration with the pharmaceutical companies for one reason: profit – the selling of prescription slips and the selling of drugs. Psychiatry has degenerated into nothing more than drug-pushing. And the process of pathologizing normal problems of living continues. The much-heralded DSM-5 promises even further inroads in this direction.
The fundamental problem with the APA’s approach emerges from their definition of a mental disorder:
… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress…or disability…or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom. (DSM-IV-TR, p xxxi)
If you examine this definition carefully, it is clear that it means nothing more than: any significant human problem.
It’s a castle built from sand. The logic is as follows:
- Any human problem is a mental disorder.
- X is a human problem
- Therefore X is a mental disorder!
As facile and ridiculous as this sounds, it is exactly what has happened. The simple assertion that childhood misbehavior is a mental illness explains nothing. It is simply a device used to legitimize drugging these children.
And the real causes underlying these problems are never even pursued. Parents are off the hook; the school is off the hook; the community is off the hook. And the cash registers at the pharmacy go ker-chung.
And similar considerations apply to all the other DSM creations. Depression is not an illness. It is a feeling we get in response to a major loss or when things are not going well for us. It has been pathologized by the APA and the pharmaceutical companies for gain. The so-called bipolar disorder is not an illness – it is largely rudeness and irresponsible behavior – again pathologized for gain.
It is said that the drugs work, so why quibble? Well the simple answer is that they don’t work nearly as well as the psychiatric hype would have us believe. But this post is already too long; perhaps we can pursue this another time.
Once again, apologies to my regular readers for the repetition. Medical blog, if you’re still reading, I can appreciate how a medic, schooled in the rigors of scientific research, might view all this with a measure of skepticism. It’s a great deal easier to dismiss me as a crank than to face the alternative: that modern psychiatry is an enormous hoax which is draining dollars from genuinely needed services and undermining notions of self-help and personal responsibility that are keystones of a thriving society. Please feel free to come back on any of these issues. It’s not just a question of trying “harder and smarter.” Some of the problems that confront people are truly overwhelming and require outside help. But they are not illnesses and the help needed is not drugs.