04 March 2008

Non-legitimised dissatisfaction = illness

As readers of the book will know, a mediocracy ...

... relies on the suppression of criticism. Anomalous cases of dissatisfaction need to be identified as pathological. It is desirable to associate such anomalies with physiology, as this contributes support for physicalism.

Unhappiness should be presumed to be caused by a chemical deficiency or by incorrect thinking. It cannot be caused by dissatisfaction with, for example, the opportunities available for intellectuals. A mediocratic culture must be presumed to cater for all real (i.e. socially recognised) needs.

People expressing feelings of dissatisfaction should be regarded as requiring treatment. They should be strongly encouraged to take whichever drugs will cause them to stop complaining, whether these are drugs for happy feelings or — if necessary — drugs for no feelings at all.
Support for my cynicism about the ludicrous catch-all which the term depression has become is now available from two recent books.

Horwitz and Wakefield's The Loss of Sadness argues that the huge increase in diagnosed cases of clinical depression has arisen because of loose criteria and a failure to distinguish between sadness and illness, leading to a high proportion of false positives. Will Wilkinson, reviewing the book for Reason Magazine, writes that
... if you meet five of nine mundane requirements over the course of two weeks, you qualify as suffering from major depression. The checklist: a persistently low mood, a diminished interest or pleasure in almost everything, an increase or decrease in appetite leading to a gain or loss in weight, too much or too little sleep, fatigue or low energy, fidgetiness or listlessness, feelings of worthlessness or guilt, difficulty concentrating or indecisiveness, and thoughts of death, suicide, or an attempt of suicide.

The DSM [Diagnostic and Statistical Manual*] admits a single exception: If the symptoms are precipitated by the death of a loved one, they represent normal grief and there is no disorder. But as Wakefield and his team showed in a 2007 study, one in four people diagnosed with major depressive disorder exhibited symptoms only negligibly different than that of the bereaved. They too were responding to major losses; it’s just that the precipitating events were not deaths.
It isn't just existing concepts from psychopathology, such as autism, which have become inflated to cover any deviation from the acceptable average. Perfectly normal behaviours have become transformed into sicknesses. Boredom and restlessness among children, for example, have become pathologised into ADHD. A book by Christopher Lane makes the same point about shyness and argues that it was rebranded as a sickness via a banal procedure involving design by psychiatric committees. According to Jerome Burne writing in the TLS, Lane's book
reveals the inner workings of the committee that sat for seven years and drastically revised the [DSM] manual, creating 112 new disorders, including Social Phobia — later changed to “Social Anxiety Disorder” — the “shyness” of Lane’s title.

Officially, that revision transformed the manual and, by extension, psychiatry into a “pristine scientific entity”. This was done partly by removing virtually all traces of the psychoanalytic model of mental functioning from the definitions and symptoms. Out went all the unprovable speculations about psychosexual dramas of the ego and the id, and in their place an “atheoretical” system was created that listed only symptoms and was agnostic about cause; a system that could be quantified and standardized much more easily.

[However, far] from being the distillation of new research and scientific studies, the new disorders emerged from rounds of bureaucratic infighting and the sort of wheeler-dealing that produces the manifestos of political parties. On one occasion, during a forty-minute meeting, Professor Robert Spitzer, the chairman of the revising committee, together with two other psychiatrists, apparently decided that the old diagnosis of “hysterical psychosis” should be split in two. One was to be characterized by “short episodes of delusion”, the other by “showing up in an emergency room without authentic cause”. The first they called “brief reactive psychosis”, the second “factitious disorder”. Spitzer typed out the list of symptoms for each, then and there.

... In fact the process could be even vaguer. Some disorders were included on the basis of just one patient, treated by the same clinician who was putting the disorder forward. In other cases the symptoms wouldn’t have seemed out of place in a saloon-bar discussion. Signs of “chronic complaint disorder” include grumbling too much about the weather or saying “Oy vay” too many times.
Such crude compartmentalisation is perhaps inevitable in a situation in which there is not only no satisfactory theoretical model of mental illness, but in which any kind of model is, in a sense, taboo. The idea that people might have a complex inner mental life, beyond simple programming of a kind extrapolatable from biology, has become controversial and is therefore avoided. This is perhaps because it is inconsistent with the preferred mediocratic model of the individual. The mediocratic individual must be like everyone else; ergo, it is necessary to explain him/her exclusively using physical and social concepts, avoiding reference to subjective mental life as far as possible. Not surprisingly, the ability of this approach to contribute usefully to understanding mental illness has proved limited.
... the real tragedy of [the revised DSM] was that it produced a dumbed-down form of psychiatry that takes little account of the complexities of the unconscious, and its influence on our behaviour, as identified by Freud. The checklists of behavioural symptoms used to diagnose disorders in [DSM] take no account of a patient’s personal history. And concentrating on externals in psychiatric diagnosis takes little account of how symptoms are experienced by the patient. Maybe that wouldn’t matter if the medical drug model had been successful. This postulates that certain behaviours indicate a neurochemical deficiency — analogous to, say, low insulin — which can be returned to a healthy level with a drug. Quite apart from its shaky biochemical basis ... the results of applying it have not been impressive.
* * * * *

It is somewhat gratifying to see a bit of a backlash against the supposed 'depression' epidemic, and against the crudified model of psychology it reinforced.

Sadly, the two books and their reviewers allow several other myths to escape unscathed. First, the idea that there is some 'normal', socially permitted period for feeling bad about a loss, and that if you exceed it, you are justifiably labelled as 'ill' — meaning you become an appropriate target for chemicalisation, with the threat of it being compulsory not that distant. Even without legally enforced compulsion there is of course pressure from society in the form of experts, employers and family members, all of whom are likely to buy into the prevailing consensus and demand that the 'patient' takes his medicine.

Second, the possible reasons for over-medicalisation, which are regarded worthy of discussion by the reviewers, appear to be confined — as is typical — to the profit motive, reinforcing the ideology that somehow capitalism is to blame. There is the usual resistance to the possibility that those given power to label others as pathological (doctors, psychiatrists, social workers) are likely to have a strong bias in favour of exercising that power, compared to just leaving people alone. Especially in the presence of an ideology which disapproves of leaving things as they are, on the grounds that this is anti-progressive.

An idea which I have not seen discussed is that the West really could be experiencing an increase in depression (in the old-fashioned sense of that word) but that this is caused not by capitalism but by mediocracy. The grimness of contemporary culture — reductionist, (pseudo)proletarianised, over-sexualised, aggressified — could conceivably be making a lot of people feel hopeless and unwilling to get out of bed in the morning, particularly perhaps younger people. I am not advocating this as a theory, but I do find it curious that this version of the depressed-society story gets no airtime, when the anti-capitalist version gets so much.

Finally, a contribution from the Sunday Times's India Knight. Ms Knight comments on recent research which has put the once-celebrated Prozac and other SSRI treatments in a poor light. Her own recommendation is for "more talking".
when you hear of GPs handing out Prozac like sweeties — even when someone has specifically gone in to talk and get things off their chest rather than to ask for drugs — you can’t help but wonder whether the medical profession is more comfy writing prescriptions than entering into a dialogue.
Yes, but it isn't doctors' job to "enter into a dialogue". Nor should we encourage them to make it so. There is already too much tendency for them to take on extracurricular roles (policeman, social worker, moral philosopher, etc).

Ms Knight asks:
Does feeling desperate because your ex-wife won’t let you have access to your children make you mentally ill and in need of a prescription, or might it just be a question of talking to someone?
Actually, neither.

* the standard handbook used by clinicians to classify mental problems