What Should Count As A Disease?
What exactly is a "mental disorder"? For that matter, what criteria should determine whether any condition is a "disease" or a "disorder"?
and attempts an answer. It is this:
This is not a failing of Pies; there's no possible way he could be expected to come up with a concrete solution. But his answer is just as ambiguous, relative, and subject to individual prejudices as simply defining a disease as "anything in which the person or surrounding people feel suffering. Severity of illness correlates to amount of suffering."
I'm not saying my definition is better-- it's equally valid, or invalid, or whatever you want to believe this whole project is.
It should be fairly obvious that "disease" is an entirely subjective term that can be applied legitimately to anything. "The disease of right wing conservative ideology." See? 50% of you agreed. Not jokingly agreed, mind you-- but found a serious element of truth to that diagnosis.
Point is: people can't be trusted to value anything. Remember that idiotic book Nudge? Look where it got us.
II.
You may want to ask whether "what constitutes a disease?" is something you really want the answer to. If it turns out that alcoholism is not a disease, then what? Close all the rehabs?
Trying to determine what is, or what is not, a disease is a distraction, a red herring. The real question is, what are we going to do about that thing?
The Average Joe is at a bit of a disadvantage. He feels something's amiss with say, "ADHD is a disease" but doesn't have the language to articulate it. So he says, "ADHD isn't a disease because it's too vague, not based on any physical pathology." He says that, because he's trying to argue like he thinks a doctor might argue, using the word "pathology" or using definitions. Consequently, his perfectly legitimate suspicion is dismissed, because his arguments seem weak to a doctor.
He needs to be true to himself. He doesn't need to argue it on doctors' terms, doctors need to argue it on his terms, because it's a social problem, not a scientific one.
His real problem with the diagnosis is what he's actually best suited to speak about: the social ramifications. "If you call ADHD a diagnosis, does that mean he gets extra time on the test and I don't?" That's the part that matters. Whether ADHD is "real" or not, whether there is a gigantic gaping pus hole in a "patient's" brain where something important should be is not what matters to Joe. What matters is, "he got this far even with the pus hole, why should he get a leg up just because he can't do as well as I can?"
Pies tries to argue like a doctor, because he thinks this is going to be decided by doctors. He doesn't realize that it has already been decided, by forces larger than him and Joe.
As if to reinforce that point, here is the advertisement found between Pies's article:
There's a social problem masquerading as a medical problem. Oh, you think it's a Pharma ploy to make money? Nope. Society wanted Pharma to take this problem off their hands. If you're wtaching it, it's for you.So what if it's true? Do we believe that treating ADHD will lower the divorce rate? Should having ADHD mean you get to keep the boat?
No one would dispute that the symptoms of ADHD exist, or even that they cluster together, or that they respond to Dexedrine. It's probably likely this is related to some physical change. But? What does having this mean? Does it mean society is obligated to pay for it? Defer to it? Those are the questions that matter, not whether it is a "disease."
The word "disease" is a safe house, it's "base." It's a clever accounting trick. Since "diseases" are defined to be value neutral and require both money and deference, rather than argue whether ADHD is worth our money and time, instead argue whether it is a disease. Once it gets labeled as a disease, no further arguments are necessary-- it's a disease. Don't be a heartless jerk. Step aside.
That drives Joe bananas. And it should.
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April 24, 2009 1:54 PM | Posted by : | Reply
Excellent post. Kind of gets into a discussion on lesswrong.com about how many moral beliefs are really just tantamount to "yayy"ing things you like and "boo"ing things you don't. I'm in a bit of a rush at the moment so I can't get the link for you, but if anyone wants it let me know and I'll comment again later whne I have some time with it. It is worth it. Again, excellent post.
Score: 4 (4 votes cast)
April 24, 2009 1:58 PM | Posted by : | Reply
Nevermind, I have some time. Here is the link: http://lesswrong.com/lw/bk/the_trouble_with_good/
I highly encourage everyone to read it.
Score: 3 (3 votes cast)
April 25, 2009 1:29 AM | Posted by : | Reply
Who wouldn't do better on that exam with an extra hour and getting to take it cranked on Dexedrine? The problem is that Joe could easily fake having such a pus-hole his brain, get extra time and performing-enhancing drugs for the test, and nobody can prove Joe's pus-hole is fake any more than they can prove Mr. ADHD's pus-hole is real.
Score: 1 (1 votes cast)
April 25, 2009 4:17 AM | Posted by : | Reply
I really think you should read stages 4 and 5 in the cited article. They'd knock down more than a few of your straw men. And pharma? Of course pharma wants to make big money. They just spent a quarter million dollars with focus groups to figure out which fear buttons needed to be pushed in order to maximize their greatest gains. Then they needed their pet dog to push it. Enter Shire, inc.
Then they spent a million dollars to advertise it. And you dismiss the idea that it's "a pharma ploy." Well you're only right if you define a ploy as an ineffective, amateurish attempt to promote some sort of conditioned response. Or that it's just pharma. These guys ... these suits and these ad execs and these docs are pros, pure and simple.
What about Joe? Joe doesn't give a shit about some hypothetical extra hour on some hypothetical test you made up in order to attempt to make some weak point. Joe just wants Junior to STFU and he's damn happy to address the problem with whatever one-stop med does the job.
And the real poltroons? Dr. David Goodman and C. Brendan Montano, MD? Hey man ... they just want to make some fast bucks ... no big deal. That's why they signed on with the Shire gig. In a very real sense, fear plus Shire's marketing of ADHD is helping two hack doctors buy another vacation home somewhere ... hopefully in the US so the economy gets stimulated.
Always follow the money. Always.
Score: 0 (0 votes cast)
April 25, 2009 2:44 PM | Posted by : | Reply
It seems to me that you don't have to find (or rule out) the equivalent of a gaping pus-hole to make a ADHD decision/diagnosis. You see both of these people in campus mental health centers all the time:
1. People with a documented history of trouble in the domains you'd expect, with performance to match. Funny enough, this is generally not the first time this concern has come up in their lives, and they have a nice thick history.
2. People with no reliable history of academic problems. This person frequently has no past interaction with psychologists because in the past they never saw themselves as having a problem. This person has a stable academic history until college, and now it is starting to crumble.
Most practitioners around here are not going to think much of #2's claim of ADHD. Why should they? We all have limits, academic and otherwise, and when we reach those limits we run into problems.
I'm not suggesting that past history is the only factor in determining whether someone has ADHD. But since most of the hard, verifiable evidence (school related) becomes infinitely more difficult to obtain in adults it rapidly turns into a situation where the client comes in complaining of X,Y,Z symptoms and comes out with a prescription for stimulants. This doesn't end well, in the school or workplace.
Psychopharms make out like bandits with #2, though, so look forward to seeing 70 year old amphetamines put on the market every few years with a new mix-in to keep the patent (and exponential price tag) fresh.
Score: 1 (1 votes cast)
April 25, 2009 3:42 PM | Posted by : | Reply
Ah ha. That explains the multiple divorces. Will print and take ad to doctor pronto.
Score: 4 (4 votes cast)
April 25, 2009 4:34 PM | Posted by : | Reply
From the linked article:
Finally, in stage 5 (“fully realized disease entity”), we are able to specify the precise chromosomal and biomolecular etiology, and the phenomenology, for all disease subtypes. (The term “biomolecular etiology” should not be construed as precluding a role for social and psychological factors, however).
When psychiatrists call something a "disease", this often carries an implication about its cause (e.g. that it is due to trauma, genetics, or pathogens), that it can be investigated using a particular type of method, and that it will eventually be treatable with a particular type of treatment (usually, drugs).
All of these are claims that can turn out to factually false. When you get to his stage 5, you may find out that chromosomes and molecular biology have nothing whatsoever to do with the phenomena you're investigating. Or that drugs are not the way to deal with it. Or - perhaps more likely - you never get to stage 5, because your entire research prgram is based on a false premise (that the phenomenon has genetic/biochemical causes, and the problem is to find them).
Note the sleight of hand, where in phase 1 we can have anything at all that causes suffering and incapacity, but by the time we get to phase 5, every type of suffering and incapacity - no matter what it is - necessarily turns out to have a genetic and biomolecular cause.
Score: 1 (1 votes cast)
April 25, 2009 7:52 PM | Posted by : | Reply
The definition is not that difficult and has been articulated since Virchow.
An illness is a condition in which an abnormal pathology (localized in the individual) causes pain and suffering. Virchow, the great pathologist, realized that dead people are not ill, though they do have pathology, because they do not suffer.
A disease is the same as the above but the pathology deteriorates over time.
Asperger's is an illness, but not a disease. In most models Asperger's (like congenital deafness) does not deteriorate over time. These conditions are caused by brain pathology and they cause pain and suffering. Bipolar is a disease because it is caused by brain pathology, there is pain and suffering, and the brain deteriorates over time.
Small cancers in the prostate in the elderly are neither illnesses nor diseases because they do not cause pain or suffering, though they are associated with pathology. (People die of things other than small prostate cancers when they are elderly.) When we learn to prolong life, small cancers of the prostate in the elderly will become diseases, because they will cause pain and suffering by shortening life.
You may wish to check-out very long arguments about the existence of mental illness/definitions of disease. These discussions are usually between psychiatrists and physical scientists who are bright people but do not believe in the existence of mental illness.
http://www.settingtheworldtorights.com/node/438
Check out the science and superstition entry and the On Fake Diseases entry.
A few psychiatrists defend the profession against hard scientists (not nutty people) who in general believe that mental illness is fake.
Score: 1 (1 votes cast)
April 25, 2009 8:57 PM | Posted, in reply to , by : | Reply
Bipolar is a disease because it is caused by brain pathology, there is pain and suffering, and the brain deteriorates over time.
The only thing undeniable there is the pain and suffering.
We do not know what the brain pathology is.
And where is the proof of deterioration over time?
Score: 0 (0 votes cast)
April 26, 2009 3:06 AM | Posted by : | Reply
Asperger's Syndrome is a good example - is it located in the individual?
You might, for example, want to know why it is being diagnosed more often now than it was in the past. On a disease model, you'ld look for some change in the patients, that causes more of them to have the condition. But the other effect you have to allow for is that (a) it's now a fashionable diagnosis and (b) the level of symptoms required for a diagnosis is lower than it was in the past. That is, a significant part of the change may be a behavioural change in psychiatrists, not in their patients. So you'ld want to know what has happened to psychiatrists, to make them more likely to diagnose this condition.
Nearly all the conditions that are called "mental illness" manifest in social situations involving more than one person. One of them gets identified as the person who has the "illness". But was this the right choice? Should you be measuring some property of the other people? etc.
Score: 0 (0 votes cast)
April 27, 2009 7:51 AM | Posted by : | Reply
"We are Borg. You will be assimilated. Resistance is futile."
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April 27, 2009 11:20 AM | Posted by : | Reply
People will never take mental disorders seriously because it's part of the magical world of the brain. The brain apparently regulates our bodily systems, remembers things, and produces headaches, but it certainly doesn't determine our behavior. We do that.
Should we give special support to people who claim ADD? We support dyslexics, and they seem to have done ok with a hole in the head. Everyone is limited in some capacity by their bodily specifics. I'll never mix paint for a living or become a jockey. A lot of people can't realistically expect to become a doctor or physicist. Despite our fervent desire to believe we're all equal, it ain't so. I guess we either need to accept that, or keep trying to level the field.
Score: 0 (0 votes cast)
April 27, 2009 12:19 PM | Posted by : | Reply
I think there might be an ADHD disease. But the thing is that there are a lot of posers. I know a person diagnosed with ADHD and the thing about him is that he is utterly incapable of acting "normal" in every area of life. He acts the same at work, when he vollenteers, at home, and at school.
The fakers, on the other hand, only have problems in one or two areas. They can't sit still at school, but sit them down in front of an XBOX and they won't move for hours. Or they'll be able to memorize football stats without ADHD trouble, but can't buckle down to do homework.
The rule of thumb that works for me is that a disease is more likely to be real if it affects everything and to the point where other people notice it everywhere you go. In most cases I think you'll eventually discover a brain disfunction as well, but brain science is in its infancy, so it may be that no cause is discovered YET.
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April 27, 2009 3:54 PM | Posted by : | Reply
I wonder how many diagnosed mental disorders are actually symptoms of an underlying, non-psychiatric disorder? How many panic attacks are hypoglycemic events? How many attention disorders are sleep related? It looks to me like any condition that isn't obvious and/or potentially fatal can easily be labeled by its behavioral/neurological consequences instead of its whole.
At present, things like IBS seem galling. There is no real disorder, you're just fabricating and exaggerating it. Try to be less stressed.
Most people seem satisfied with saying "this person is suffering because they're anxious," without asking "why is this person so disposed to anxiety?"
Score: 1 (1 votes cast)
April 28, 2009 11:50 AM | Posted by : | Reply
A lot of diagnosis is driven by expediency and it's ability to be efficiently monetized. You could have a barista tech doing 75% of what a doctor does in his/her office. Take vitals, order blood tests, fill out the paperwork that drives this outmoded, overpriced, inefficient health system. Yawn.
Transfer this approach to the mental health system. Take a 30-45 minute standardized oral inventory, blackberry your checklist, come up with an insurance approved medication and refer to a specialist. Yawn.
You actually want to explore etiologies? Get real. It's not cost effective.
Score: 1 (1 votes cast)
April 28, 2009 7:30 PM | Posted, in reply to , by : | Reply
Differences in genes account for up to 80% of the differences in whether someone will get bipolar I disorder or not. Differences in genes imply differences in proteins. Those with these differences in genes and proteins (on average) have multiple deteriorating brain regions, as documented by repeated brain imaging. Abnormal pathology causing deterioration in brain functioning, associated with pain and suffering, is the definition of disease. Bipolar illness is a disease.
Michael Golding
Score: 2 (2 votes cast)
April 28, 2009 7:41 PM | Posted, in reply to , by : | Reply
Are you implying that Asperger's is caused by bad parents, bad culture, or incompetent psychiatrists because the diagnosis is now made more frequently?
Diabetes frequency has dramatically increased, as well. Definitions of diabetes change over time, like the definition of Asperger's. Whether someone is hearing impaired, has diabetes, or has Asperger's depends on the definition because these conditions exist on a spectrum. But auditory nerve damage in those who are hearing impaired, cellular metabolic abnormalities in diabetes, and brain abnormalities in Asperger's are not in doubt, regardless of the extent of the damage.
Score: 1 (1 votes cast)
April 29, 2009 9:21 AM | Posted, in reply to , by : | Reply
"Nearly all the conditions that are called "mental illness" manifest in social situations involving more than one person."
I see what you're getting at here, but it's an overstatement. While there is a "social functioning" component in most of the diagnostic algorithms, impairments don't stop when one's alone. In mood and psychotic disorders people hurt, hurt themselves, and struggle to tend to themselves, isolation or no. They often avoid people, if only because they can't even deal with themselves.
I think that what people object to are often "personality disorders," which are pretty subjective. Personality implies an observer, per your statement.
Score: 2 (2 votes cast)
April 29, 2009 10:23 AM | Posted by : | Reply
Swine Flu (or any Influenza for that matter) I wouldn't call a disease but then again a definition of disease is subjective to everyone.
Herpes, HIV, HBV/HCV could count as they fall into the lifelong, chronic condition category these days.
Viral infections, no matter what kind, cannot be cured though. Never have and most likely never will. Only prevented and treated but not cured. Fascinating considering that a virus isn't even a living organism.
Score: 0 (0 votes cast)
April 29, 2009 11:22 PM | Posted by : | Reply
It's funny because psych co-opts everything as it's own disease. It makes social constructs out of certain actual ailments. I was 17 years old and suddenly had chest pain, tightness in chest, trouble breathing (I'm asthmatic, but I was on Advair and wasn't wheezing), tingling in extremities, lightheadedness, etc. one day right before an Algebra exam. I had chest palpitations as well and basically passed out.
The high school called an ambulance, where they did an EKG. The paramedics told the hospital on the radio that I was having a heart attack or some kind of cardiac event. I got to the hospital and things were a bit calmer at that point. The doctor went "it's extremely unlikely that you were having a heart attack at your age. What were you doing when this happened?" I told him that I was ready to take an Algebra exam. "Oh, then it's likely panic. Let's get a psych consult."
So ten minutes later a Sikh doctor shows up and starts talking about Paxil and Xanax. The ambulance guys came back over and were like, "he was HAVING a HEART ATTACK. Why aren't you doing anything?" Apparently the original ER doc stopped reading my chart after I mentioned the Algebra exam and missed the whole EKG thing. I was rushed to a cardiologist who found out that I had a massive detached clot lodged close to my heart.
I know now that panic often presents as chest pain in ERs. But maybe I'm crazy enough to think that you should rule out the worst case first. I probably would be very dead if it was not for the paramedics looking out for me.
Score: 4 (4 votes cast)
April 30, 2009 7:11 AM | Posted by : | Reply
But maybe I'm crazy enough to think that you should rule out the worst case first.
No, you are not crazy.
Score: 1 (1 votes cast)
April 30, 2009 9:34 AM | Posted, in reply to , by : | Reply
This sums up the plaintiff's arguments in the other post about Zyprexa. Jurors already have this idea that doctors take a symptom (e.g. fever) and run through all the possibilities, ruling out the worst. In practice, they are subject to every bias out there, including familiarity.
This applies to geography as well: if you have a fever in a medical ER you get an entirely different work up than a fever on a psych unit, even though the patient, symptoms, and his meds are the same.
The difficulty for an expert witness is to separate lazy practice from the standard of care, which is why it's so important to explain that the doctor didn't have to do the best job, he only had to do a reasonable job that others would have done.
Score: 1 (1 votes cast)
May 1, 2009 11:58 PM | Posted by : | Reply
Symptoms don't occur in isolation though... fever is just one symptom. Whether or not the patient is in an ER or a psych unit, if fever occurs with labile BP, muscle spasms/neck contortion (ie other symptoms of NMS)... and if the patient admitted to the ER comes with family who say he is on risperidal..., any ER doc worth his salt is going to consider NMS as one of the potential reasons behind the fever. In addition to, you know, pathogenic causes. Similar I would like to think that in any psych unit, pathogenic causes of fever are going to be considered too.
I'm an RN. We have a resident who is very agitated due to dementia, he is being weaned off risperidal and started on seroquel due to EPS. Last night at change of shift my resident began spiking fever. I did think "possible NMS" but considering the fact that he has been having loose BMs and has a history of cdiff, the more likely cause is going to be a return of the cdiff which was inadequately eliminated first round of flagyl.
So I notified the physician and we put him on isolations and collected a stool and I encouraged fluids and gave him tylenol and blah blah blah.
I mean, in the real world, there is a history, and there are other symptoms that make up a picture.
I think the problem is we are blaming "familiarity" as the cause of sucking, when the real problem is the individual practitioners... a whole lot of people just suck at doctoring and they aren't thinking outside the box because they are apathetic about their job or they are mentally uncreative.
Score: 1 (1 votes cast)
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