Tuesday, March 2, 2010

Cryola, in all colors

Existential angst
We've already posted some on this (here), but we've been thinking some more about last week's reports of revisions to the formal categorization of psychiatric diseases, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Given the reordering and recategorizing done in this revision, many people will have woken up last week no longer having the disorder that they had just the day before. That's difficult enough, but the deeper question is what it means that diseases can come and go at the drop of a 943 page tome. 

Science magazine has a piece (subscription required) on this.  They write about co-morbid conditions, in which mental disorders don't exist in their 'pure form', but instead categories overlap, and, for example, substance abuse and anxiety tend to ride along with other mental disorders, particularly depression. 
DSM-IV, currently in use, gives a menu of nine symptoms for "major depression," a diagnosis that afflicts about 17% of the population at some point in life, according to the U.S. National Comorbidity Survey. (Bipolar illness—depression alternating with mania—affects another 1%.) Missing from the list is anxiety; yet, says Fawcett [psychiatrist at the University of New Mexico School of Medicine in Albuquerque, and chair of the DSM-V work group on mood disorders], anxious depressives are at greater risk for suicide, and there's a "staggering" fivefold difference in response to antidepressants, with nonanxious depressives doing much better. Fawcett's group is therefore recommending that "mixed anxiety depression," a condition that has been residing in the Appendix of DSM-IV, be promoted to a freestanding diagnosis.
But giving anxiety a higher status within depression raises other categorical questions. The "anxiety disorders" are currently a separate category that includes generalized anxiety disorder, phobias, and panic, as well as obsessive-compulsive disorders and post-traumatic stress disorder. The symptoms defining the latter two are far more varied than those associated with depression and anxiety.
The piece further reports:
Indeed, DSM-V authors are debating whether the relationship between anxiety and depression is so close that they should be subsumed into a supercategory of human hopelessness, fear, and existential angst.
Don't we all feel this at some point, to some degree, whether or not we meet the criteria for diagnosis and treatment for a disorder? This is not to say that some people don't suffer terribly from depression or anxiety, by any means. These are very real conditions, and can be utterly debilitating.

But much of this is about medicalizing what used to be considered normal, driven at least in part by pharmaceutical companies out to make huge profits by selling medications that people will take for life. Watch commercials by these companies and you'll never feel normal again: shyness has been turned into 'social anxiety disorder', and of course there's a medication for it. And similarly, baldness or erectile dysfunction or toenail fungus can all be treated now, and while this might be welcome news to sufferers, it's much more welcome to the keepers of the pharmaceutical bottom line.  Indeed, the BBC reports that 'experts' say that 'pain should be viewed as a disease in its own right' and treated appropriately.    

We've written before about the need for science to be based on trust. Is the struggle to categorize anxiety and depression going to bring us any closer to a 'truth' about mental illness, and to easing the pain of the sufferers, or is all this recategorizing primarily about further enriching big pharma?  What should we believe?

And of course this category creep makes studies of causation even more difficult because the more heterogeneous the cases, the less likely they'll share a cause, be it genes or environmental factors or a combination of both. 

Crayola Deficit Syndrome
In that same light, we were interested to read the story in the NYTimes last week about families in which occupational therapists are now being hired to help children improve their handwriting.
These days, many little fingers are being drilled. Twenty-five years ago, pediatric occupational therapists primarily served children with severe disabilities like spina bifida, autism or cerebral palsy. Nowadays, these therapists are just as focused on helping children without obvious disabilities to hold a pencil.
So even handwriting difficulties are being medicalized. Parents desperate to have their children hold their Crayons right! If not, they need therapy, lest they become Signature Challenged adults! To qualify for that, a diagnosis! Crayola Deficit Syndrome!  

This a push-pull situation that is either good for everybody or bad, depending on your point of view.  The parents pull for diagnoses that can make them feel better (a label seems to make the worrisome scrawls understood and qualified for treatment, and even curable), and the various professional interests push (to expand their client base, drug customers, special-ed teachers). 

The reality is more continuous, a spectrum of variable traits. At the extremes, no one would argue that diagnosis and treatment aren't meaningful. But we're pushing rapidly from the extremes toward the middle. Maybe some day being 'average' will be considered a diagnostic trait, since if your kid is 'average' s/he is behind other kids and you'll demand a diagnosis and a therapist to fix this.

This may seem rather silly, but not for the reason you think. We would not want our progeny to be Signature Challenged, but after all, when our kids grow up, there won't be any signatures or handwriting. It will all be by bar-scans, keyboards or voice recognition. The really savvy parents will be checking their kids voiceprints, not their scrawls. So, relax! There's no need to Cryola over misspelt 'milk'.

**Louis Menand expands on many of the same points we make here in a fine review of a book on the history of depression and another on the history of the drug industry in the March 1 New Yorker.  He says, among other things, that the redefinition of traits that were once considered normal, such as shyness, has 'juggernaut effects'.  Scientists then get grants to find 'the gene for shyness', and build research institutes to study it, 'even though there was never any evidence that the condition has an organic basis'.  

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