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Mama, we're all crazy now

MagazineMarch 2015 (Vol. 25 Issue 12)Mama, we're all crazy now

Being overly creative, non-conformist or questioning of authority are new definitions of a mental disorder, according to the latest volume of the psychiatrists' 'Bible'

Being overly creative, non-conformist or questioning of authority are new definitions of a mental disorder, according to the latest volume of the psychiatrists' 'Bible'

People who are eccentric, antiestablishment or oppose authority have a mental health problem called 'oppositional defiant disorder' (ODD), which can be treated with powerful antipsychotics, according to the latest version of the psychiatric 'Bible'.
ODD was first designated a mental disorder in the early 1980s, but has only recently been redefined by the American Psychiatric Association (APA) in its latest edition of the Diagnostic and Statistical Manual of Mental Disorders (or DSM-5), a major reference textbook that lists and explains all known mental illnesses that can be treated by psychiatrists.

Although seen mainly as a childhood disorder characterized by defiant, angry or irritable behaviour, ODD apparently affects adults too. According to DSM-5, ODD is defined as "an ongoing pattern of disobedient, hostile and defiant behaviour", and the symptoms include questioning of authority, negativity, defiance, argumentativeness and being easily annoyed.

In short, says clinical psychologist Bruce Levine, the new mental disease of ODD is a declaration that "any non-conformity and questioning of authority is a form of insanity". What were once called 'personality traits' to describe a difficult, antisocial or creative outsider are now mental diseases. In the previous volume, known as DSM-IV, other personality traits like arrogance, narcissism, above-average creativity, cynicism and antisocial behaviour also became treatable mental illnesses.

An ODD diagnosis is often made hand-in-hand with one for ADHD (attention-deficit/hyperactivity disorder). Children who display four out of eight behaviours persistently for more than six months could be diagnosed with ODD; the behaviours include being 'touchy' or easily annoyed, argumentative, actively refusing to comply with the requests of 'the majority' or 'consensus-supported rules', spiteful, blaming of others and doing things to 'deliberately annoy others'.

The APA isn't sure why some people suffer from ODD, but believe it can be the result of a combination of biological, psychological and environmental factors. Treatment can range from behavioural therapy, positive reinforcement, praise for 'appropriate behaviour' and, of course, ADHD drugs like Ritalin.

Out of order

Studies have reckoned that 11.2 per cent of all males and 9.2 per cent of females suffer from ODD, while 52 per cent of ODD patients who aren't treated will still have behavioural problems three years later and that half of these will develop into a behavioural pattern dubbed 'conduct disorder'.

Not surprisingly, the whole issue of ODD-from its causes to its diagnosis and treatment-is mired in controversy. The World Health Organization (WHO) has different criteria for assessing ODD, and others have said that the lines between ODD and ADHD have become so blurred that accurate diagnosis is almost impossible. There's also the problem that psychiatric diagnoses are ultimately subjective and that any annoying, eccentric or creative person could be labelled an ODD patient. By that reckoning, virtually every genius, artist or radical reformer would be considered mentally ill and could include Jesus, Leonardo, Einstein and even America's own fathers of the Revolution, Thomas Jefferson and George Washington.

It's so subjective, in fact, that Thomas Insel, director of the US National Institute of Mental Health (NIMH)-the highest American mental-health government official-stated in 2013 that the DSM's diagnostic categories lacked validity and that the NIMH would be "reorienting its research away from DSM categories"-in other words, the Institute was going to ignore them. In the same year, Allen Frances, former chairman of the Task Force that defined mental diseases for DSM-IV, broke ranks and announced that psychiatric diagnosis, as administered by the APA, was out of control.

Drug ties

So what has gone so wrong? For Frances, psychiatry had gone the way of medicine and become another delivery system for the pharmaceutical industry. Indeed, by the time DSM-5 was being prepared, 69 per cent of the Task Force had ties to the pharmaceutical industry, an increase of 21 per cent on the team that had been headed by Frances.

The close ties between psychiatry and the pharmaceutical industry have been noted for some years. In 2008, US Congressional investigations into psychiatry discovered that the APA and several 'thought-leader' psychiatrists, including Harvard University child psychiatrist Joseph Biederman, were taking money from drug companies and this was influencing their judgements. According to The New York Times, Biederman's work "has helped fuel an explosion in the use of powerful antipsychotic medicines in children", and he earned at least $1.6 million in consulting fees from drug companies between 2000 and 2007.

It was later revealed that Biederman had "pitched" his upcoming research project to drugs manufacturer Johnson & Johnson, promising the study would find in favour of its antipsychotic Risperdal-and so it proved. Biederman maintained that the payments did not influence him, but Massachusetts General Hospital and Harvard Medical School didn't agree and disciplined him-along with two other psychiatrists-for violating their conflict of interest policies.

ODD isn't the only mental illness with dubious origins. Sales of SSRI (selective serotonin reuptake inhibitor) drugs-including Prozac, Paxil and Zoloft-average around lb5 billion a year and are regarded as a major therapy for depression because doctors still cling to the theory that depression is caused by a chemical imbalance and especially by low levels of serotonin, a brain chemical and neurotransmitter.

The idea was promulgated by the APA from the 1960s onwards-but it has quietly tip-toed away from it since 2011 without telling anyone. Indeed, the APA now maintains it never accepted the theory, even though it helped to launch one of the most lucrative families of drugs with an effectiveness that cannot be anything more than a placebo. Writing in the Psychiatric Times, its editor-in-chief Ronald Pies stated: "In truth, the 'chemical imbalance' notion was always a kind of urban legend-never a theory seriously propounded by well-informed psychiatrists."

Chemical imbalance was among the great wave of 'mental illnesses' defined by the APA over the last half-century. Around a century ago, psychiatrists recognized just seven mental disorders, but this increased to 59 just 20 years later, and the total rose dramatically 50 years ago when 130 mental disorders were identified.

By 2010, the count had risen to 374, with 77 of them 'discovered' since 2003. But even a serious mental condition like schizophrenia may be overdiagnosed and overtreated, says NIMH's Insel. After analyzing many studies into the characteristics and treatment of schizophrenia, Insel concluded that, in the long-term, people with psychoses fare better without medication.

His views were echoed by the late Dr Thomas Dorman, a cardiologist and medical 'skeptic' who died in 2009, when he said: "The whole business of creating psychiatric categories of disease, formalizing them with consensus, and subsequently ascribing diagnostic codes to them, which in turn leads to their use for insurance billing, is nothing but an extended racket furnishing psychiatry a pseudo-scientific aura. The perpetrators are, of course, feeding at the public trough."

But the lone voice of the maverick is being drowned out by an industry and profession that seeks to medicate our mental problems away. Some 54 million people around the world are taking an antidepressant even though the idea of a chemical imbalance has been discredited. In the US, one in five women is taking medication for a mental disorder, while one in seven prescriptions in France is for a psychotropic drug, with half the French working population taking an antipsychotic.

According to the NIMH, 26 per cent of Americans are suffering from mental illness, and nearly 58 million will "suffer from an episode of mental illness in any given year". Add to that the new definitions of mental illness-ODD, eccentricity, over-creativity, arrogance, narcissism, cynicism, questioning of authority and antisocial behaviour-and we'll all be crazy soon.

Was Einstein ODD?

Many mavericks, creatives, great thinkers and social reformers throughout history would be diagnosed with ODD, according to the latest definitions, and would probably have ended up heavily medicated.
Clinical psychologist Bruce Levine is convinced that physicist Albert Einstein, who came up with the theory of relativity and is considered one of the greatest-ever geniuses, had many of the characteristics of the typical ODD patient.

He didn't pay attention to teachers, failed his college entrance exams twice and had difficulty holding down jobs. Einstein biographer Ronald Clark asserts that the great man's problems didn't stem from ADHD or ODD disorders, but from his hatred of the authoritarian and Prussian discipline in the schools he attended. When he did eventually enter college, one of his professors told him: "You have one fault; one can't tell you anything."

Defining mental illness

The subjectivity of a diagnosis of a mental disorder was laid bare by a landmark experiment in the 1970s by psychology graduate David Rosenhan. He had eight sane people, including himself, attend various hospitals and declare they were hearing voices. Using the then current edition of the DSM, psychiatrists diagnosed seven of the eight with schizophrenia and they were admitted to a mental institution. During their stay, they reverted back to their normal behaviour, yet their sanity was never once noticed by the staff. Even when they were released, the participants were still labelled as schizophrenic, except one who was given a new diagnosis of schizophrenia in remission.

An enemy of the state

The new definitions for a diagnosis of ODD-questioning authority, being antiestablishment-have sinister overtones harking back to a period in the history of Russia when it was under Communist control.

In 1959, the USSR leader Nikita Khrushchev announced that anyone who opposed the 'ideal' state of communism must be suffering from a mental disorder. Any opposition was a sign of insanity, and 'Communist deniers' were rounded up and treated in mental institutions. A few years earlier, Stalin's leading psychiatrist Andrei Snezhnevsky had invented a new condition, 'sluggish schizophrenia', to purge the state of malcontents. This condition was cited by Khrushchev as the mental problem of the new enemies of the state. Prominent dissidents were pronounced insane and spent years in forced-labour camps or locked up in psychiatric hospitals.

In 1970, the American Psychiatric Association made Snezhnevsky a 'Distinguished Fellow' for his "outstanding contribution to psychiatry and related sciences".

REFERENCES
1 J Am Acad Child Adolesc Psychiatry, 2010; 49: 435-6
2 J Am Acad Child Adolesc Psychiatry, 1992; 31: 539-46
3 PLoS Med, 2012; 9: e1001190
4 The New York Times, June 8, 2008; www.nytimes.com/2008/06/08/us/08conflict.html?oref=slogin&_r=0


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