Monday, May 14, 2012

Medicalizing Everyday Behavior

D.S.M. Revision May Sharply Increase Addiction Diagnoses:

In what could prove to be one of their most far-reaching decisions, psychiatrists and other specialists who are rewriting the manual that serves as the nation’s arbiter of mental illness have agreed to revise the definition of addiction, which could result in millions more people being diagnosed as addicts and pose huge consequences for health insurers and taxpayers.

The revision to the manual, known as the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., would expand the list of recognized symptoms for drug and alcohol addiction, while also reducing the number of symptoms required for a diagnosis, according to proposed changes posted on the Web site of the American Psychiatric Association, which produces the book. 

In addition, the manual for the first time would include gambling as an addiction, and it might introduce a catchall category — “behavioral addiction — not otherwise specified” — that some public health experts warn would be too readily used by doctors, despite a dearth of research, to diagnose addictions to shopping, sex, using the Internet or playing video games.

As I have been writing for years now, the revision of the D.S.M. is going to represent the single largest expansion of the biomedical view of "madness" ever undertaken in history.  It will assert, beyond all measure, the total control of the psychiatric-industrial complex.
While other medical specialties rely on similar diagnostic manuals, none have such influence. “The D.S.M. is distinct from all other diagnostic manuals because it has an enormous, perhaps too large, impact on society and millions of people’s lives,” said Dr. Allen J. Frances, a professor of psychiatry and behavioral sciences at Duke, who oversaw the writing of the current version of the manual and worked on previous editions. “Unlike many other fields, psychiatric illnesses have no clear biological gold standard for diagnosing them. They present in different ways, and illnesses often overlap with each other.” 

Dr. Frances has been one of the most outspoken critics of the new draft version, saying that overly broad and vaguely worded definitions will create more “false epidemics” and “medicalization of everyday behavior.” Like some others, he has also questioned whether a private association, whose members stand to gain from treating more patients, should be writing the manual, rather than an independent group or a federal agency.

Frances has separate opinion piece in yesterday's NYT wherein he calls for breaking up the "psychiatric monopoly" and blasts the arbitrariness of such revisions.
The fourth edition of the manual, released in 1994, tried to contain the diagnostic inflation that followed earlier editions. It succeeded on the adult side, but failed to anticipate or control the faddish over-diagnosis of autism, attention deficit disorders and bipolar disorder in children that has since occurred.

Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role. 
Certainly, but I still think Frances is underestimating the corrosive relationship between Big Pharma and the psychiatric-industrial complex, which we now know was one of the leading forces behind the explosion of autism, bipolar and ADHD in children over the past 15 years.

Yet, we continue to fall prey to the idea that psychiatric diagnoses found in adults can be found in children as well, as this bizarre piece in the same edition of the NYT's argues "Can A 9-Year Old Be A Psychopath?"
Currently, there is no standard test for psychopathy in children, but a growing number of psychologists believe that psychopathy, like autism, is a distinct neurological condition — one that can be identified in children as young as 5. Crucial to this diagnosis are callous-unemotional traits, which most researchers now believe distinguish “fledgling psychopaths” from children with ordinary conduct disorder, who are also impulsive and hard to control and exhibit hostile or violent behavior. According to some studies, roughly one-third of children with severe behavioral problems — like the aggressive disobedience that Michael displays — also test above normal on callous-unemotional traits. (Narcissism and impulsivity, which are part of the adult diagnostic criteria, are difficult to apply to children, who are narcissistic and impulsive by nature.)

In another famous case, a 9-year-old boy named Jeffrey Bailey pushed a toddler into the deep end of a motel swimming pool in Florida. As the boy struggled and sank to the bottom, Bailey pulled up a chair to watch. Questioned by the police afterward, Bailey explained that he was curious to see someone drown. When he was taken into custody, he seemed untroubled by the prospect of jail but was pleased to be the center of attention.
See also: narcissism, impulsiveness, and the lack of discipline/boundaries in the kid's life. In other words, a few extreme examples (and no one is sure whether the story above was actually true since it was based solely on the Pokemon-like fantasies of a 9 year old kid) are taken as "evidence" that something is amiss with kids today and suddenly we are over-pathologizing to the point where diagnostic fantasies, such as "firstborn syndrome," come about to excuse away poor parenting and bad behavior in kids.

Nonetheless, the expansion of madness under the D.S.M.-V, like mold, promises to be all-encompassing and total. If you, your family and your neighbors are exhibiting thoughts or emotions or behaviors that fall outside of societal norms (however benign they may actually be), you will eventually end up diagnosed with some sort of psychological malady and be given psychotropic medication to bring you back in line.

It is the ultimate in social control.

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