Dateline: Sun, May 18, 2008
Only in the United States is the idea of runaway commerce at the center of the health system regarded as “normal.” As might be expected, the “medicalization” of social and political deformities has reached truly grotesque dimensions in America.
By Dr. Susan Rosenthal | [print_link]
When you are sick or injured, you want to know what’s wrong and what can be done. You want a diagnosis. A correct diagnosis reveals what is wrong, what is the preferred treatment and what is the likely outcome. For example, a diagnosis of pneumonia indicates a serious lung infection that can usually be cured with antibiotics.
While medical diagnoses are based on science, psychiatric “diagnoses” are not at all scientific. They do not reveal what is wrong, what is the preferred treatment, and what is the likely outcome. Nor are they reliable. Different psychiatrists who examine the same patient typically offer different “diagnoses.” Moreover, psychiatric “diagnoses” move in and out of favor at different times.
Psychiatric “diagnosis” is actually a labeling process, where the patient’s symptoms are matched with a grouping of symptoms listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Psychiatric Disorders (DSM). As we shall see, this psychiatric “bible” was developed and is maintained by financial and political interests.1
Who decides what is normal or healthy and what is deviant or sick?
Before the 20th century, life stresses were generally seen as spiritual problems or physical illnesses, and people turned to religious advisors and physicians for help. Medical doctors treated “hysteria” and “nerves” as physical problems. Psychiatry was restricted to the treatment of severely disturbed people in asylums.2 The first classification of psychiatric disorders in the United States appeared in 1918 and contained 22 categories. All but one referred to various forms of insanity.
In 1901, Sigmund Freud revolutionized psychiatry by breaking down the barrier between mental illness and normal behavior. In The Psychopathology of Everyday Life,3 Freud argued that commonplace behaviors – slips of the tongue, what people find humorous, what they forget and the mistakes they make – indicate repressed sexual feelings that lurk beneath the surface of normal behavior.
By linking everyday behavior with mental illness, Freud and his followers released psychiatry from the asylum. Between 1917 and 1970, as psychiatrists cultivated clients with a broad range of problems, the number of psychiatrists practicing outside institutions swelled from eight percent to 66 percent.4
The social movements of the 1960’s opposed psychiatry’s focus on inner conflict and emphasized the social sources of sickness instead. Dr. Alvin Poussaint recalls the 1969 convention of the American Psychiatric Association (APA).
“After multiple racist killings during the civil rights movement, a group of black psychiatrists sought to have murderous bigotry based on race classified as a mental disorder. The APA’s officials rejected that recommendation, arguing that since so many Americans are racist, racism in this country is normative.”5
Growing the industry
In 1980, the APA overhauled the DSM. The Task Force established to create the new manual declared that any disorder could be included,
“If there is general agreement among clinicians, who would be expected to encounter the condition, that there are significant number of patients who have it and that its identification is important in the clinical work it is included in the classification.”6
In other words, the new DSM was not based on science, but on the need to maintain existing patients and include new ones who might seek help for any number of problems. A profitable and self-perpetuating industry was born. The more people could be encouraged to seek treatment, the more conditions could be entered into the DSM, and the more people could be encouraged to seek treatment for these new conditions.
By 1994, the DSM listed 400 distinct mental disorders covering a wide variety of behaviors in adults and children. Significantly, racism, homophobia (fear of homosexuality) and misogyny (hatred of women) have never been listed as mental disorders. In 1999, the chairperson of the APA’s Council on Psychiatry and the Law confirmed that racism “is not something that is designated as an illness that can be treated by mental health professionals.”7 Homosexuality was listed as a mental disorder until activists campaigned to have it removed.8
The women’s liberation movement condemned labeling symptoms of oppression as mental illnesses. In They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, Paula Caplan explains,
“In a culture that scorns and demeans lesbians and gay men, it is hard to be completely comfortable with one’s homosexuality, and so the DSM-III authors were treating as a mental disorder what was often simply a perfectly comprehensible reaction to being mocked and oppressed.”9
Caplan describes efforts to prevent “Masochistic Personality Disorder” from being included in the DSM. This disorder assumes that women stay with abusive spouses because like to suffer, not because they lack the resources to leave. Despite protest, “Masochistic Personality Disorder” was added to the 1987 edition of the DSM, although it was later dropped.
The inclusion of “Pre-Menstrual Dysphoric Disorder” (PMDD) in the DSM also raised a protest. According to Caplan,
“The problem with PMDD is not the women who report premenstrual mood problems but the diagnosis of PMDD itself. Excellent research shows that these women are significantly more likely than other women to be in upsetting life situations, such as being battered or being mistreated at work. To label them mentally disordered – to send the message that their problems are individual, psychological ones – hides the real, external sources of their trouble.”10
As soon as PMDD was listed in the DSM, Eli Lilly repackaged its best-selling drug, Prozac, in a pink-pill format, renamed it Serafem, and promoted it as a treatment for PMDD. By creating Serafem, Lilly was able to extend its patent on the Prozac formula for another seven years.
A marketing gold mine
The DSM is a marketing gold mine for the drug industry. The FDA will approve a drug to treat a mental disorder only if that disorder is listed in the DSM. Therefore, each new listing is worth millions in potential drug sales. Most of the experts who construct the DSM have financial ties to pharmaceutical companies, and every new edition of the DSM contains more conditions than the previous one.
Once the DSM lists a new mental disorder, drugs for that disorder are heavily marketed for everyone who might fit the symptom checklist. (Doctors are also encouraged to prescribe these drugs for “off-label use,” which means to anyone they think might benefit.) Not surprisingly, the numbers of people “diagnosed” with a mental condition rise rapidly after a drug is approved to treat that condition.
In 2005, a major study announced that “About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life…11 How is this possible? Has it become normal to be mentally ill, or has the definition of mental illness expanded beyond reason? Both could be true.
Capitalism damages people in many ways. It’s also true that the more people can be labeled as sick, the more profits can be made from selling them treatments. In Creating Mental Illness, Alan Horowitz warns,
“…a large proportion of behaviors that are currently regarded as mental illnesses are normal consequences of stressful social arrangements or forms of social deviance. Contrary to its general definition of mental disorder, the DSM and much research that follows from it considers all symptoms, whether internal or not, expected or not, deviant or not, as signs of disorder.”12
Most people know the difference between normal behavior (such as grief over the death of a loved one) and abnormal behavior that could indicate an internal disorder (such as prolonged grief for no apparent reason). However, the DSM does not consider what happens in people’s lives. With one exception (Post-Traumatic Stress Disorder), the DSM lists and categorizes symptoms outside of any social context. As a result, DSM-based surveys artificially increase the numbers of people suffering from mental disorders and, therefore, the market for drug treatments.
DSM-inflated rates of mental illness are typically accompanied by the warning that not enough people are getting treatment,13 which serves to further expand the market for drugs. The question of whether all these people are actually sick is never raised, nor is the question of whether their symptoms might be linked to physical illnesses.
Many physical diseases generate psychological symptoms. Researchers estimate that from 41 to 83 percent of people being treated for psychiatric disorders are actually suffering from misdiagnosed physical diseases like hyo- or hyper-thyroidism, heart disease, immune-system diseases, nervous system diseases (including multiple sclerosis) and cancer.14 Undiagnosed and untreated, these physical diseases can progress to cripple or kill. Furthermore, psychiatric drugs can worsen physical diseases, sometimes fatally. None of these “costs” are borne by the pharmaceutical industry – the most profitable industry in America.
Psychiatry has a long history of medicating the oppressed, including children, for social control.15
Schools force youngsters to sit still in closed rooms for long periods of time and force-feed them information that has no connection to their lives. Those who rebel are diagnosed with mental disorders (Attention-Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, etc.) and forced to take mind-altering drugs. To preserve a crazy-making system, the healthy child must be made “crazy.”
Using DSM criteria, at least six million American children have been diagnosed with serious mental disorders, triple the number in the early 1990’s. The rate of boys aged 7 to 12 diagnosed with Bipolar Disorder more than doubled between 1995 and 2000 and continues to rise.
A 2007 survey of 8- to 15-year-olds discovered that nine percent met the DSM criteria for attention deficit/hyperactivity disorder (ADHD). The survey found that fewer than half of these children had been diagnosed or treated, “suggesting that some children with clinically significant inattention and hyperactivity may not be receiving optimal attention.” Noting that poor children were least likely to receive medication, the authors of the study recommend “further investigation and possible intervention.”16
Instead of addressing the oppressive social conditions that agitate children, psychiatry imposes conformity through medication. To force compliance with this oppressive system, access to insurance benefits, medical care and social services depends on “having a diagnosis.”
Most of the symptoms listed in the DSM describe human responses to deprivation and oppression (anxiety, agitation, aggression, depression) and the many ways that people try to manage unbearable pain (obsessions, compulsions, rage, addictions). Depression is strongly linked with poverty,17 and alleviating poverty can lift depression.18
The suffering of war veterans is labeled as a mental disorder (PTSD) instead of the inevitable consequence of war. These soldiers are sick because they have been violated. Their symptoms express their anguish and outrage at the barbarism they witnessed and perpetrated. What’s sick is sending good people into the hell of war.
Schizophrenia is designated as a mental illness that is assumed to be genetic. However, studies from several countries show that living in a city gives a person a higher probability of developing schizophrenia than having a family member with the disease. Moving from rural to urban centers increases the risk of developing schizophrenia, while moving in the other direction reduces the risk.19 City living is associated with increased stress and trauma, exposure to lead,20 infection,21 malnutrition,22 and racial discrimination23– all of which are linked with higher rates of schizophrenia.
Under capitalism, addressing the social sources of sickness is politically risky and unprofitable. So psychiatry extracts the individual from society, splits the brain from the body, severs the mind from the brain and drugs the brain.24
A sick society
Capitalism is a social system that requires the majority to have no control over their lives and to accept this as “normal.” Therefore, all reactions to inequality and deprivation are portrayed as signs of personal inadequacy, biological defect, mental illness – anything other than reasonable responses to unreasonable conditions.
During slavery days, experts argued that Black people were psychologically suited for a life of slavery, so there must be something wrong with those who rebelled.25 In 1851, the diagnosis of “drapetomania” (runaway fever) was developed to explain why slaves try to escape.26
Not much has changed. Today, exploitation and oppression are considered normal, and those who rebel in any way are considered to be sick or deviant and in need of “treatment” or punishment.
What’s the diagnosis for a sick society? We know what’s wrong. A few people accumulate wealth and power at the expense of everyone else. What’s the treatment? Capitalism must be replaced with a socialist society that generates health, not sickness. Who can deliver the medicine? The global working-class majority. What’s holding us back? Lack of organization.
I don’t expect this diagnosis to appear in the DSM anytime soon.
Dr. Susan Rosenthal has been practicing medicine for more than 30 years and has written many articles on the relationship between health and human relationships. She is also the author of Striking Flint: Genora (Johnson) Dollinger Remembers the 1936-1937 General Motors Sit-Down Strike (1996) and Market Madness and Mental Illness: The Crisis in Mental Health Care (1999) and Power and Powerlessness. She is a member of the National Writers Union, UAW Local 1981. She can be reached through her web site or by email at firstname.lastname@example.org
The story of why and how she became a physician and social activist is eloquently told here.
1 Kirk, S.S. & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine De Gruyter.
2. Horowitz, A.V. (2002). Creating mental illness. Chicago: University of Chicago Press.
3. Freud, S. (1901/1991). The psychopathology of everyday life. New York: Penguin
4. Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the age of Prozac. New York: John Wiley & Sons.
5. Poussaint, A.F. & Alexander, A. (2000). Lay my burden down: Suicide and the mental health crisis among African-Americans. Boston: Beacon Press, p.125.
6. Spitzer, R.L., Sheeney, M. & Endicott, J. (1977). DSM III: Guiding principles. In Psychiatric diagnosis, (Eds). Rakoff, V., Stancer, H. & Kedward, H. New York: Brunner Mazel.
7. Egan, T. (1999). Racist shootings test limits of health system and laws. New York Times, August 14, p.1.
8. “DSM and homosexuality: A cautionary tale.” in Kirk, S.A. & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine De Gruyter p 81-90
9. Caplan, P. (1995). They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal. New York: Addison-Wesley, pp.180-181.
10. Caplan, P.J. (2002). Expert decries diagnosis for pathologizing women. Journal of Addiction and Mental Health. September/October 2001, p.16.
11 Kessler, R.C. et. al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. Vol.62, No.6, pp.593-602.
12. Horowitz, A.V. (2002). Creating Mental Illness. Chicago: University of Chicago Press. p.37.
13. Talen, J. (2005). Survey says nearly half of all Americans will be affected by a mental illness, some before adulthood. Newsday, June 7.
14. Klonoff, E.A. & Landrine, H., 1997, Preventing misdiagnosis of women: A guide to physical disorders that have psychiatric symptoms. Thousand Oaks, CA: Sage
15. Breggin, P.R. & Breggin, G. R. (1994). The war against children: How the drugs, programs, and theories of the psychiatric establishment are threatening America’s children with a medical ‘cure’ for violence. New York: St. Martin’s Press.
16. Froehlich T.E., et. al. (2007). Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Arch Pediatr Adolesc Med. Vol.161, pp.857-864.
17. Duenwald, M. (2003). More Americans Seeking Help for Depression. New York Times, June 18.
18. Costello, E.J., Compton, S.N., Keeler, G. & Angold, A.(2003). Relationships between poverty and psychopathology: a natural experiment. JAMA. Oct 15, Vol.290, No.15, pp.2023-9.
19.. Pedersen, C.B. & Mortensen, P.B. (2001). Evidence of a dose-response relationship between urbanicity during upbringing and schizophrenia risk. Arch Gen Psychiatry. Vol. 58, No. 11, pp.1039-46.
20. Calamai, P. (2004). Lead exposure in womb linked to schizophrenia. Risk also found if mother had flu: 1960’s U.S. data help unravel mystery. The Toronto Star, Feb. 15.
21. Opler, M.G.A. et al. (2004). Prenatal lead exposure, -aminolevulinic acid, and schizophrenia. Environmental Health Perspectives, Vol.112, pp.548-552.
22. St Clair, D., Xu, M., Wang, P. Yu, Y., Fang, Y., Zhang, F. Zheng, X., Gu, N., Feng,G., Sham, P. & He, L. (2005). Rates of adult schizophrenia following prenatal exposure to the Chinese Famine of 1959-1961. JAMA. Vol.294, No. 5, pp.557-562.
23. Joan Arehart-Treichel, J. (2003). Is schizophrenia a downside of urban life? Psychiatric News (American Psychiatric Association) May 16, Vol.38, No.10, p.37.
24. Ross, C.A., & Pam, A., (1995). Pseudoscience in biological psychiatry: Blaming the body. New York: Wiley.
25. Poussaint, A.F. & Alexander, A. (2000). Lay my burden down: Suicide and the mental health crisis among African Americans. Boston: Beacon Press.
26. Cartwright, S. (1851). Report on the diseases and physical peculiarities of the Negro race. New Orleans Medical and Surgical Journal. May, p. 707.