The notion of a professional group such as the APA sitting in their councils and committees inventing illnesses for themselves to treat seems so preposterous that a measure of disbelief on the part of the reader is understandable. In its historical context, however, the development is not so surprising. The original 1952 DSM was very simple and unpretentious, and whilst part of the APA’s motivation in drafting the document was undoubtedly to draw some credibility and respectability to their profession, there is at the same time nothing to suggest any great drive at that time towards aggrandizement or service expansion. However, having agreed in 1952 that neurosis was a form of mental disorder, it was inevitable that subsequent revisions of the manual would attempt to define this feature further and look for subdivisions of the general category. This, of course, is exactly what has happened, and the current version of DSM lists literally dozens of disorders of this sort, although the general term neurosis is no longer used. (For an interesting discussion of this matter, see Karen Franklin’s post at In The News.)
Trichotillomania is a case in point. DSM-IV describes trichotillomania as a mental disorder in which the victim, usually a female child, twists, tangles, and pulls out her hair in a compulsive, habitual manner.
The reality is that children play with their hair, and children also frequently develop dysfunctional and counterproductive habits, such as picking their noses, putting their fingers in their mouths, etc.. It is likely that children have displayed hair-tangling and hair-pulling tendencies since before people lived in caves. Parents from generation to generation have dealt with these kinds of problems as a matter of course, as an integral part of the normal parental responsibilities.
Functional, effective parents intuitively use the normal systems of coaching, teaching, rewards, punishments, etc., in a more or less systematic attempt to instill productive habits in their children and eliminate dysfunctional ones. This includes hair-pulling. Certainly up till a generation or so ago, no parents would have conceptualized this as anything other than a habit, and the matter would have been resolved promptly within the family using natural methods of coaching, encouraging, etc..
Today, however, thanks to the widespread “consciousness raising” of the APA and the pharmaceutical companies, a growing number of parents have accepted the notion that a child displaying this kind of behavior has a mental disorder and needs immediate professional attention. Newspaper ads and free screenings, both paid for by pharmaceutical companies, promote these ideas and frequently suggest that failure to seek prompt treatment may result in matters becoming a good deal worse.
The treatment usually involves a psychotropic prescription, the side effects of which frequently are far more destructive to the child’s health than the original problem. The child is also “enrolled” in the ranks of the mentally disordered, and is given the false notion that it is impossible to deal with life’s normal problems without the assistance of professionals and pills. He or she is well on the road to customer-for-life status, which of course benefits the practitioners and the pharmaceutical companies.
In this context it is important to note that the question “is trichotillomania a mental disorder or not?” becomes meaningless, because there is no definition of a mental disorder other than the one the APA provides. If the APA says something is a mental disorder, then it is, otherwise it is not. There is no external reality to which their findings must conform. By contrast, a geologist, for instance, who asserted that wood is a form of rock would be rebutted on the grounds that wood simply does not have the objective qualities and characteristics of rock, and no amount of discussion or consensus can alter that reality. A psychiatrist, on the other hand, who suggests that road rage, for instance, is a mental disorder, merely has to persuade enough of his colleagues that this is the case, and it will become so by being included in the next edition of DSM. It is the psychiatrists who decide what is a mental disorder, and their general philosophy in this regard for the past fifty years has been “the more the merrier.” A recent editorial in the American Journal of Psychiatry, for instance, asserts that Internet addiction is a mental disorder and should be included in the next edition of DSM.
In general, business has been good for psychiatrists in recent decades. Clients are indeed seeking their help for an increasingly wide range of problems, and it is likely that DSM-V, when it emerges, will list even more mental disorders than the current edition.
Calling a problem a mental disorder obviously does not change the nature of the problem, nor does it provide any special insight into the matter. The fact is that most children play with their hair. For a very small number the habit becomes strong, and they actually tear hair out in significant quantities. When psychiatrists say, “This is a mental disorder,” essentially what they are saying to the parent is, “You can’t take care of this. You must bring this child in for treatment.” The disempowering aspect of the message is not usually articulated, but parents who succumb to these kinds of pressures do in fact become disempowered and ineffective, and usually relegate an increasing measure of their parental responsibilities to the professionals. This, of course, is good for business, but the results in terms of the child’s general development are often far from satisfactory. Furthermore, by defining the problem as something inherent to the child, the system is ignoring the role the parents may have played in the creation and maintenance of the problem, and in general, little or no attempt is made to empower or coach them towards more effective parenting. (For an interesting perspective on this, see codeblog’s post about a day in the children’s psych ward.)
In the context of diagnostic proliferation, it needs to be recognized that psychiatry is a profession, and that the APA’s primary agenda – rhetoric notwithstanding – is to promote the welfare and interests of their members. That’s why the individual psychiatrists join and pay their dues (currently $540 a year). Like other professional groups, they window-dress their documents and their press releases with public welfare platitudes, but also like other professional groups, they protect their own interests and fight tenaciously for their turf.
It should also be acknowledged that in the turf protection area, psychiatrists have enjoyed a great deal of success and have become extraordinarily adept at lobbying legislators and other decision-making bodies in matters that affect psychiatry’s financial interests. In this regard they have had the wholehearted assistance of the pharmaceutical companies, who have used their formidable advertising and lobbying power to full advantage in the drive to develop the mental disorder framework and to promote its acceptance by the American people. Pharmaceutical companies routinely fund most of the “free screenings” for depression and other so-called mental disorders that one sees advertised in the newspapers and on TV. Their funding sources are seldom acknowledged in the ads, but can usually be verified by calling the 800 number and asking where the funding comes from. In addition the pharmaceutical companies donate large quantities of money to organizations sympathetic to their cause, for instance, the National Alliance for the Mentally Ill (NAMI), and have in recent years begun targeting ads for psychotropic drugs directly towards potential patients.
The central theme of this website is that the APA’s framework, in which an increasingly wide number of human problems are conceptualized as mental illnesses and best treated by psychotropic drugs, is spurious and counterproductive. It is a disempowering philosophy that undermines not only the value and integrity of the individual affected, but also saps the strength, vitality, and creativity of our families and communities. In the following posts I will discuss some of these so-called diagnoses in more detail.
Next post: Attention Deficit and Disruptive Behavior Disorders