In February, a group of physicians writing in the Journal of the American Medical Association reported that the use of “psychotropic medications prescribed for preschoolers increased dramatically between 1991 and 1995.” About twice as many children between the ages of 2 and 4 were given Ritalin, Prozac, and other so-called psychotropic drugs at the end of that period as at the beginning of it. In a front-page story, the New York Times cited experts calling the finding “very surprising.” It is about as surprising as finding the proverbial fox feasting on chickens. In a paper published in January 1957—at the dawn of the “new psychiatric revolution”—I stated that psychiatric drugs are “chemical straitjackets,” controlling, not curing, the denominated patients.
In my last column (May), I commented about the nineteenth-century epidemic of mental illness called “masturbatory insanity.” In this column, I comment about our present-day epidemic of mental illness called “attention deficit hyperactivity disorder (ADHD).”
To grasp the enormity of the stupidity that informs these so-called diagnoses, we must be clear about the difference between a diagnosis and a disease.
Webster’s dictionary defines diagnosis as “The art or act of identifying a disease from its signs and symptoms.” According to The Oxford English Dictionary (OED), it is the “Determination of the nature of a diseased condition; . . . also, the opinion (formally stated) resulting from such investigation.”
The concept of diagnosis is contingent on the concept of disease. Diagnosis is the name of a disease, just as, say, violet is the name of a flower. For example, the term “diabetes” names a type of abnormal glucose metabolism. The disease qua somatic pathology—literal disease—is the abnormal metabolism; the diagnosis, “diabetes,” is its name. Somatic pathology is diagnosed by finding abnormalities (lesions) in bodies or body parts. Disease qua somatic pathology may be asymptomatic and changing the nosology (classification of disease) can change the name but not the reality of somatic pathology as disease. Unless we keep in mind that diseases are facts of nature, whereas diagnoses are artifacts constructed by human beings, we forfeit the possibility of understanding the uses and abuses of the term “diagnosis.”
Manipulating things is difficult, sometimes impossible. Manipulating names is easy; we do it all the time. Violet may be the name of a flower, or a color, or a woman, or a street. Similarly, a disease-sounding term may be the name of a bodily malfunction, or the malfunction of a car, a computer, an economic system, or the behavior of an individual or group. We cannot distinguish between the literal and metaphorical uses of the term “disease” unless we identify its root meaning, agree that it is the literal meaning of the word, and treat all other uses of it as figures of speech. In conformity with traditional medical practice, I take the root meaning of disease to be a bodily lesion, understood to include not only structural malfunctions but also deviations from normal physiology, such as elevated blood pressure or depressed red cell count. If we accept this definition, then the term “diagnosis,” used literally, refers to and is the name of a disease, and used metaphorically, refers to and is the name of a non-disease.
By identifying diagnosis as an opinion, the OED recognizes that it refers to a judgment. Typically, the process of diagnosing disease begins with the patient himself: he has aches or pains, feels feverish or fatigued, and judges that he is ill. If he complains about his body, then—in a medical context—his complaint constitutes a symptom, a medical-sounding word that implies that the patient’s experience is a manifestation of a disease. The point to keep in mind is that a symptom may or may not indicate the presence of a (real) disease. Whether a symptom is or is not a manifestation of disease depends on its confirmation or non-confirmation by objective data.
Diagnosing Disease: Cui Bono?
Unlike bodily illnesses, mental illnesses are diagnosed by finding unwanted behaviors in persons or by attributing such behaviors to them. Bodily illnesses—say, cancer or diabetes-are located in bodies; mental illnesses—say, kleptomania or schizophrenia—are located in social contexts. Robinson Crusoe could suffer from cancer, but not from kleptomania.
The diagnosis of a mental illness validates its own disease status. Disease qua psychopathology cannot be asymptomatic and changing the nosology can change disease into non-disease and vice versa (for example, homosexuality into civil right and smoking into substance abuse). Mental diseases are diagnoses, not diseases. Conversely, psychiatric diagnoses (however constructed) are, by definition, mental diseases (or “disorders,” to use the mental health professionals’ preferred weasel word).
To understand the tactical rather than descriptive uses of terms such as “ill” and “patient,” we must—following Cicero(106-43 B.C.)—ask: Cui bono? Cicero explained the importance of posing this question, primarily to oneself, as follows: “When trying a case [the famous judge] L. Cassius never failed to inquire, ‘Who gained by it?’ Man’s character is such that no man undertakes crimes without hope of gain.”
Mutatis mutandis, no man asserts that he or someone else has an illness without hope of gain. The goods that a person gains from asserting such a claim range from securing medical help for himself to justifying controlling the Other by defining coercion as cure. Consider the evidence:
- The disease of masturbation affected mainly children; so does the disease of hyperactivity.
- The disease of masturbation pained parents, teachers, and other adults, not the denominated patients; the disease of hyperactivity pains and does not pain the same persons, respectively.
- The disease of masturbation was treated with physical restraints forcibly imposed on the bodies of children; the disease of hyperactivity is treated with chemical restraints forcibly introduced into the bodies of children.
- The disease of masturbation was the favorite diagnosis of doctors and parents dealing with troublesome children in the nineteenth century; attention deficit hyperactivity disorder is the favorite diagnosis of doctors and parents dealing with troublesome children today.
Belief in masturbatory insanity was, as I emphasized, not an innocent error. Neither is belief in ADHD. Each belief is a manifestation of the annoyance that many ordinary childhood activities cause adults, of the adults’ efforts to control or eliminate such activities to allay their own discomfort, and of the medical profession’s willingness to diagnose disturbing childhood behaviors, thus rationalizing and justifying the domestication of children by drugs defined as “medication.”
Formerly, quacks had fake cures for real diseases; now, they claim to have real cures for fake diseases.