The first approach — the biopsychosocial model — assumes that the significance of apparently identical symptoms and symptomatic behaviour can vary greatly between patients. Diagnosis focuses on the broader context (biopsychosocial), and takes the form of an extensive report focusing on the individual situation of a particular patient within a specific context. As a result, treatment must always be tailored to an individual situation.
The second approach — the medical or ‘illness’ model — takes the view that psychiatric symptoms spring from underlying bodily processes, and that the environment at most plays a role in bringing these to the fore. The point of departure is that a mental disorder is always the same, irrespective of the patient, so that the diagnosis can largely be confined to a label. Treatment follows a set protocol, involving the same guidelines for each patient, if necessary supplemented with the ‘Guidelines for deviating from guidelines’. (I’m not making this up.)
In present-day psychiatry, the illness model is dominant, although people shrink from using the word ‘illness’. They prefer to speak of ‘disorders’ — a term vague enough to avoid lawsuits.* Just how dominant the model is becomes clear if you have the nerve to champion the alternative approach. The response is incredulous. Autism, a psychological problem? Schizophrenia, a social disorder? The most you can hope for is a pitying look, but you’re more likely to get your head bitten off. The implication is that no serious professional would even contemplate voicing such heresies. I shall come back to this shortly.
[* Trudy Dehue pointed out to me that all English-language commercial websites formulate information about possible neurobiological processes and genetic causes of mental disorders in the conditional tense. The reason is that the lack of hard scientific evidence could lead to companies in the United States being sued for providing misleading information, were they to present it as a fact.]
A curious shift is taking place in the way that the illness model is applied in psychiatry: symptoms — for example, attention deficit and hyperactivity — are being classified as diseases. The use of snappy acronyms camouflages this to an extent, but the trend is now so well established that it takes some effort to see that it only produces pseudo-explanations. Using this model, a man with high fever (HF) and excessive sweating (ES) would be diagnosed as suffering from HFES. The conclusion would then be that this poor man is feverish and sweaty because he suffers from HFES. Which is just like saying that a woman has attention deficit (AD) and is hyperactive (HA) because she suffers from ADHD. To put it another way: in the current version of the illness model, we constantly run up against circular arguments that only provide the illusion of a scientific explanation.1 Pronouncements such as ‘ADHD is causing attention deficit in classrooms’, or ‘A bipolar disorder causes severe mood swings’ are examples of this. The description is presented as the cause of what is being described, and the use of abbreviations means we don’t see through the trick. A final example to round off: someone who experiences sporadic outbursts of uncontrollable rage is said to suffer from IED. IED stands for ‘Intermittent Explosive Disorder’. In other words, someone has attacks of rage from time to time because he or she suffers from periodic rage attacks.
Such criticism is easily parried with the claim that only lay people talk like this, and that medical language is both more correct and founded on sound research. To establish whether this is really true, we need to ask two questions. One has to do with observation and diagnosis, and concerns the reliability of grouping certain symptoms or behaviours under the heading of a single disorder. Does everyone agree with this grouping, and can every clinician use it to reach the same diagnosis in the case of the same patient? The other has to do with causes. What evidence is there for the presumed underlying neurobiological processes and genetic causality of a specific grouping of symptoms?
To answer the first question: the way in which combinations of symptoms or behaviours are selected and classified as presumed disorders is largely arbitrary and thus highly debatable. The spectacular rise in the number of disorders in each new DSM edition alone indicates this. A more detailed look at this issue goes beyond the scope of this book, but I refer the curious reader to Shyness: how normal behavior became a sickness, by Christopher Lane. Lane was the first researcher to obtain access to the full archive of DSM compilers, along with their correspondence. His findings are shocking: the question of whether to include a disorder in the handbook and if so, in what form, has more to do with interest groups than scientific research. In the run-up to the publication of the fifth edition of the DSM, debate between such groups flared up in professional journals, as each tried to impose their own preference.
Things look even worse when you compare the DSM with its competitor, the ICD (International Classification of Diseases), published by the World Health Organisation. A diagnosis based on the DSM produces twice as many children with ADHD compared to a diagnosis based on the ICD, purely because the ICD groups symptoms differently. The ICD requires children to exhibit both impaired attention and hyperactivity; for the DSM, one of the two is sufficient. So the decision to use a particular handbook will determine whether or not your child has a disorder and — don’t forget — whether he or she needs medication. Scientifically speaking, this is bizarre, to put it mildly. Moreover, the criteria change every now and then, invariably being expanded, so that the category in question becomes increasingly blurred, and more and more people are prescribed medication. Autism is the clearest example of this kind of blurring.
The first of the above questions had to do with the grouping of symptoms into syndromes, and the extent to which scientists and clinicians agree on this subject. Clearly, they don’t. The second had to do to with causes. Nowadays, there is a conviction that the cause of a disorder must lie in bodily — that is, genetic and neurological — processes. Knowing now how difficult it is to group symptoms reliably, I find myself pondering the following question. If we don’t know whether those arbitrary groups of symptoms can only be grouped in a specific way to constitute a specific disorder, how can we then trace their underlying neurobiological processes and genetic cause? Again and again, huge individual differences emerge among, say, a group of children diagnosed with ADHD, so that to study them as if they were a homogenous group is highly dubious from an academic point of view. No wonder that no convincing evidence has been found for the presumed underlying bodily cause.
And, yes, there are findings, of course — a whole host of them — but almost every finding can be contradicted by another.2 The explanation is fairly simple. Every group that is studied contains different people with different problems, all more or less arbitrarily lumped into a group that is not a true group. Picture what would happen if we collected together everyone who suffered from HF (high fever) and ES (excessive sweating), and then studied them as if they were a single homogenous group suffering from a single condition.
We can’t escape the conclusion that in present-day psychodiagnostics, diagnostic validity — the extent to which a diagnosis indicates a real and unequivocally identifiable disease — is distressingly low. This easily explains the low reliability — the extent to which different doctors concur in their diagnosis of the same patient. The strange thing is that hardly anyone seems to lose any sleep about this, and we all just carry on as if nothing were wrong. How is it possible that, in these days of evidence-based medicine, this state of affairs — which is borne out by plenty of solid evidence — receives little or no attention? There are at least two reasons for this. The first is fairly straightforward: a dominant paradigm leads to blind faith. The second is less obvious: the illness model lets everyone off the hook. No one need feel responsible any more, let alone guilty.
Belief in paradigms versus critical science
It’s hard to overestimate the strength of paradigms. A paradigm is the orthodoxy of beliefs within a particular group (such as economists, psychiatrists, and lawyers), providing a framework that not only determines the thoughts and actions o
f the group, but also its social relationships. Heresy is not tolerated.* If it is repeatedly claimed that mental problems are individual disorders based on neurobiological processes with a genetic background, then, after a while, this becomes a ‘reality’ that can no longer be questioned. The fate of Ignaz Semmelweis (1818–1865) is a classic example of the force of paradigms in organic medicine. As a doctor in Vienna, Semmelweis was struck by the high mortality among women giving birth in hospitals: no fewer than one in four died. He found that mortality increased significantly when the doctors assisting at a birth had come straight from the autopsy room after examining a woman who had died in childbirth. This led to his theory that the doctors were transferring something — he called it ‘cadaverous particles’ — from the dead to the living woman, causing her to fall ill.
[* The term ‘paradigm’ was devised by Thomas Kuhn, who studied its impact on the evolution of scientific disciplines. Michel Foucault (1975) speaks of ‘discourse’, and looks at this in a broader social context, with the aim of exposing power structures. By way of illustration: when Alan Greenspan (who for 20 years was chairman of the Federal Reserve of the United States) had to explain the spectacular credit crisis of 2007 and 2008 and the associated failure of ‘the market’ to a committee of the House of Representatives (on 23 October 2008), the best he could come up with was that he was in a state of ‘shocked disbelief’; for him, it was simply impossible for the free market to fail. This is typical. When reality contradicts discourse, people’s spontaneous reaction is that reality, rather than the discourse, must be wrong. When we are deeply convinced of a set of beliefs, we find it hard or even impossible to accept contradictory arguments.]
As a precautionary measure, Semmelweis made his assistants scrub their hands thoroughly in a solution of chlorinated lime. The death rate rapidly fell to below 1 per cent. So what did the authorities do? They sacked Semmelweis. He became depressed and was committed to an asylum, where he died at a relatively young age. The reason his approach did not catch on was simply because it conflicted with the prevailing paradigm that diseases were spread through ‘bad air’ or miasmas. It would take another half-century before the work of the French bacteriologist Louis Pasteur gave rise to another paradigm, in which viruses and bacteria emerged as pathogens.
The current dominant paradigm in psychiatry is the illness model. This also ties in seamlessly with the reduction of science to scientism: all results must be generalisable, based on objective and value-free research using accepted methods, independent of context. I shall confine myself to two observations. The selection of certain symptoms — increasingly, of certain behaviour — as indicators of mental illness is far from value-free; rather, the reverse. And the majority of research findings may be, as we know, refuted by other findings, but this is ignored by the dominant paradigm. The psychological explanation for this is known as ‘cognitive dissonance’. As far as the DSM is concerned: with the best will in the world, the scientific underpinning for its approach is extremely weak.
The reason that so little attention is paid to the failure of current psychiatric diagnostics is thus fairly straightforward: the dominant paradigm allows no other viewpoint. The reason that labelling is such a success takes a bit more untangling. It has to do with the prevailing conviction that everyone can (and must) make a success of their lives, and that everyone is responsible for their own success or failure. For parents, this constitutes an extra burden, because on top of their own duty to succeed, they must also take on the success or failure of their children. If your child does badly at school, that’s not just a problem in itself; it also means you’ve failed. No wonder that any pseudo-medical label is gratefully accepted: it’s a disease, so I can’t do anything about it. However, internal doubt continues to gnaw — hence the aggression when someone dares to doubt the validity of those labels. And that brings us to another paradigm: disorders as social problems.
Mental disorders as social problems
The dictat of the current illness paradigm will cause a great many experts to dismiss what I have written above, arguing that these are just the tired claims of a psychoanalyst. But then what about the criticism voiced by the British Psychological Society in response to the prepublication of the new DSM, in an official document of June 2011?
The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements, with little confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations … We are also concerned that systems such as this are based on identifying problems as located within individuals.
This misses the relational context of problems and the undeniable social causation of many such problems.
Two years earlier, the WHO (World Health Organisation) had gone a step further in Copenhagen. According to its report, mental disorders are predominantly caused by social factors.*
[* ‘Mental health is produced socially: the presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual solutions … A preoccupation with individual symptoms may lead to a “disembodied psychology” which separates what goes on inside people’s heads from social structure and context. The key therapeutic intervention then becomes to “change the way you think” rather than to refer people to sources of help for key catalysts for psychological problems: debt, poor housing, violence, crime.’ (World Health Organisation, p.v.)]
Whether or not bodily factors cause or contribute to mental disorders remains open. One thing, at least, is fairly clear: psychodiagnostic criteria are based on social norms, on what is or isn’t acceptable in a certain society. To be disturbed is essentially to be ‘abnormal’ — literally, to deviate from the norm. Depending on the kind of aberration, an individual will either be punished (for indulging in such behaviours as male exhibitionism and drug addiction) or treated (for such conditions as depression or phobias). Despite the neurobiological hype, a strong link has now been scientifically and clinically established between certain forms of social organisation and the mental disorders that occur in a given society. As usual, this is easiest to see with hindsight; we are blind to what goes on in our own day and age.
Victorian society, with its repressive norms and values, produced sexually frustrated individuals bent under the yoke of an unchallengeable authority. In extreme cases, this produced typical psychoneuroses, with hysteria as the female variant, and obsessive-compulsive disorder as the male variant. These neuroses have now largely disappeared. Instead, we see an avalanche of depression and anxiety disorders among adults, and ADHD and autism among children. This is most marked in the rise in medication. According to official figures, in 2009 one in every ten Belgians was taking antidepressants, and between 2005 and 2007 the number of Ritalin prescriptions doubled. In 2011, the use of antidepressants in the Netherlands had gone up by 230 per cent over a period of 15 years; prescriptions for ADHD medication increase annually by more than 10 per cent, with the result that in 2011 the number of prescriptions exceeded one million.3 Social phobia among adults is currently such a serious problem in the West — despite it being one of the securest regions in the world — that in 2000 the Harvard Review of Psychiatry referred to it as the third most frequent psychiatric disorder after depression and alcoholism. Is it too far-fetched to assume that this general fear of others is connected to the exponential increase in evaluations, audits, performance interviews, and CCTV cameras, combined with the disappearance of authority and trust?
Finding evidence for the connection between a particular type of society and mental disorders is no simple matter. However, we can reach some plausible hypotheses. Take ADHD, for instance. Compare the need for disciplined concentration at school and at work when, not so long ago, we were required to ‘pay close attention’ with today’s world of stimulus-sensation-response in which we are constantly exposed to a barrage of inf
ormation nuggets such as text messages, tweets, and keywords. There’s no time for concentration; we’re told to be fast and flexible. A new form of superficial attention and instant response might constitute an adaptation to such an environment, but how do you prove it?
According to the British writer Mark Fisher, dyslexia should be called postlexia. Reading is out — you should instead browse, scan, skim, navigate, and jump from one hyperlink to the other. Reading books isn’t efficient, and writing books doesn’t even count towards an academic career anymore. Ten years ago, many of my colleagues and I noted that our students had lost the ability to spell, and we joked about giving dictation exercises to first-year students. These days, we’ve stopped joking about it and are seriously considering introducing a reading-comprehension course.
Hypotheses such as these, however plausible, are not scientific. If we want to demonstrate the link between a neo-liberal society and, say, mental disorders, we need two things. First, we need a yardstick that indicates the extent to which a society is neo-liberal. Second, we need to develop criteria to measure the increase or decrease of psychosocial wellbeing in society. Combine these two, and you would indeed be able to see whether such a connection existed. And by that I don’t mean a causal connection, but a striking pattern; a rise in one being reflected in the other, or vice versa.
This was exactly the approach used by Richard Wilkinson, a British social epidemiologist, in two pioneering studies (the second carried out with Kate Pickett). The gauge they used was eminently quantifiable: the extent of income inequality within individual countries. This is indeed a good yardstick, as neo-liberal policy is known to cause a spectacular rise in such inequality. Their findings were unequivocal: an increase of this kind has far-reaching consequences for nearly all health criteria. Its impact on mental health (and consequently also mental disorders) is by no means an isolated phenomenon. This finding is just as significant as the discovery that mental disorders are increasing.
What About Me?: The Struggle for Identity in a Market-Based Society Page 16
