Tuesday, November 3, 2009

The Subjectivity of Mental Illness

This week in delinquency we have been discussing Labeling theory and the subjectivity of medicalizing deviant behaviors in children and adolescents (the Frontline doc we watched "The Medicated Child" repeats tonight on most PBS stations). While the documentary focused on the exploding rates of bi-polar diagnoses amongst the toddler set, the connection was made between flimsy diagnostic criteria and other disorders such as ADHD, ODD and so on.

That's why this story caught my eye in the health section of today's NYT. Apparently, Asperger's Syndrome, a mild form of autism, is being taken out of the next edition of the D.S.M.

No sooner has Asperger consciousness awakened than the disorder seems headed for psychiatric obsolescence. Though it became an official part of the medical lexicon only in 1994, the experts who are revising psychiatry’s diagnostic manual have proposed to eliminate it from the new edition, due out in 2012.

If these experts have their way, Asperger’s syndrome and another mild form of autism, pervasive developmental disorder not otherwise specified (P.D.D.-N.O.S. for short), will be folded into a single broad diagnosis, autism spectrum disorder — a category that encompasses autism’s entire range, or spectrum, from high-functioning to profoundly disabling.

Taking Asperger’s out of the manual, known as D.S.M.-V for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, does not mean the term will disappear. But the change, if approved by the manual’s editors and consultants, is likely to be controversial. The Asperger’s diagnosis is used by health insurers, researchers, state agencies and schools — not to mention people with the disorder, many of whom proudly call themselves Aspies.
Interesting. A quick search of Asperger's reveals a telling fact regarding insurance, pharmaceuticals and treatment: there are no medications to treat Asperger's Syndrome. Simply put, the more patients diagnosed with Asperger's, the less money generated for the psychiatric and pharmaceutical industries.

Meanwhile, the more broadly proposed "Autism Spectrum Disorder" could generate prescriptions for scores and scores of various medications, as outlined here. In corporate America, they call this "planned obsolescence:" slap a discontinued product with a new label (New and Improved!) and charge even more.

Big Pharma's role should be somewhat obvious in this, and while it seems more troubling that the psychiatric industry would roll over so blatantly, this certainly isn't the first time a D.S.M. disorder has either disappeared or expanded in definition. Just a few years ago ADHD (with hyperactivity) was expanded to include "hypoactivity" (sluggish, overweight, lethargic children). Overnight, tens of thousands sufferers were added to the ADHD rolls and promptly medicated.
The proposed changes to the autism category are part of a bigger overhaul that will largely replace the old “you have it or you don’t” model of mental illness with a more modern view — that psychiatric disorders should be seen as a continuum, with many degrees of severity.

Historically, a child with the autism label could not also have a diagnosis of attention deficit hyperactivity disorder, because attention problems are considered secondary to the autism. Thus, they might go untreated, or the treatment would not be covered by insurance.

The new edition, by contrast, will list not only the core issues that characterize a given diagnosis but also an array of other health problems that commonly accompany the disorder. For autism, this would most likely include anxiety, attention disorders, gastrointestinal problems, seizures and sensory differences like extreme sensitivity to noise.
And hence, the plethora of medications which would now be available to calm and focus the child.

Back in the 1960's a psychiatrist by the name of Thomas Szasz warned about the "myth of mental illness" and the dangers of labeling behaviors that "deviate from the norm" as forms of mental illness. He used the phrase "metaphorical diseases" when referring to behaviors that are morally unacceptable but generate a psychiatric label. Today, he might include things like ADHD and ODD (Oppositional Defiant Disorder) under the same banner.

When you read the diagnostic criteria for ODD, for example, you begin to notice the many moral judgments being made. "Argues with adults," "annoys people," "blames others for his mistakes," "is angry, resentful, spiteful and vindictive." All of these are behaviors which deviate from the capitalistic norm, and thus are targeted for social control.

We find similar moral (and hence, non-scientific) judgments being made in the diagnostic criteria for ADHD. Among the many astonishingly broad behaviors listed, of note is "Does not follow through on instructions and fails to finish school work, chores or duties in the workplace."

Paging Karl Marx, Karl Marx please report to aisle "disciplined capitalistic worker."

As I always caveat with these posts, none of this is to trivialize persons with debilitating mental illness. But disorders of the brain (schizophrenia, for example) are a long way from these disorders of the mind, which Szasz wrote about nearly 50 years ago.

Thanks to Big Pharma and the omniscient psychiatric-industrial complex, we are treating, labeling, and increasingly medicalizing behaviors that fall outside the norm (symptoms) without ever locating an organic malfunction within the body. Not to be too crass, but the line between mad and bad has become increasingly blurred.

In prisons, we refer to the use of psychotropic medications as "chemical shackles." A properly medicated inmate does not require physical restraints to manage their anti-social behavior.

Similarly, the ultimate form of social control in free society would be to chemically shackle anyone who steps outside the norm. And the subjectivity of the D.S.M. gives us precisely the right tool to accomplish this.

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