The Creation of Psychiatric Ill-health
In Petteri Pietikäinen (Editor), Modernity and Its Discontents: Sceptical Essays on the Psychomedical Management of Malaise. Stockholm: Axel and Margaret Ax:son Johnson Foundation. 2005.) Svensk version
Public healthcare is suffering from increasing funding problems. At the same time, the demand for care is steadily increasing – partly because medical and technological developments are enabling more and more examinations and treatments; and partly because of an increasingly aged population.
In Sweden, the situation is complicated by the fact that the Swedes to a unique degree are afflicted by special health problems. About a decade ago, these were related especially to backache and today are related to burnout. High sick leave rates, odd geographical differences and the lack of clear diagnostic criteria indicate that the "Swedish" diagnoses have not been connected above all to deteriorating public health, nor to the discovery of new diseases. They have been related rather to changes in public attitudes, the indulgence of doctors and politicians and lax administration of sick leave.
Healthcare itself actively creates ill-health by launching debatable new diagnoses – cuckoos in the healthcare nest which entice people to discover health problems from which they would hardly suffer if the diagnoses had not existed. Psychiatry leads the way when it comes to diagnostic innovations, which create new "diseases" and needs for sick leave.
Who is mentally well or sick; who is normal or abnormal? The issue is naturally one where it is difficult to set limits. It is not surprising that people have widely disparate opinions on how limits should be set. Attitudes have been influenced especially by the changing demands of society on human adaptability, and the complexity of the matter has led to highly varying views on the development of psychiatry.
Cases of flagrant misuse have on several occasions in medical history sullied the reputation of psychiatry. This has been due above all to a chronically uncertain knowledge base, which has given innovative opportunists undue scope to launch new diagnoses and treatments. The lack of solid scientific foundations has made it possible for laymen, diverse ideological movements and political groupings to wield undue power over the development of this branch of medicine. For various reasons, society has had need of psychiatry as an implement, and all too often, it has sold its soul to dubious projects which posterity has judged harshly.
Instead of learning from experience, we find ourselves in an era more characterised by psychiatry than ever before in our history. The tendency of psychiatry constantly to change in recent decades has been reinforced through a complicated interplay between clinical activities and the commercial interests of pharmaceutical companies.
Psychiatry still adrift
Independently of how the scientific approach has varied, ever since the branch of medicine was established, psychiatry has had an obvious core. This has been care and social care of individuals with such grave adjustment problems that they have not been capable of taking care of themselves without special support. The way modern society has developed – with social networks increasingly rarefied and geographically spread – it has gradually become natural to entrust oneself to the help of the psychiatric profession when individuals fall short.
The disabling psychiatric conditions can be divided into four main categories: (1) psychoses, (2) more serious forms of affective illnesses (most commonly, depressions), (3) grave personality disorders and (4) neuropsychological disorders caused by acquired brain damage (especially dementia). The aggregate proportion of the population suffering from such conditions is fortunately limited – and probably constant, if one disregards the increase in acquired brain damage, which is due to increasing life expectancy. It is in work with weak and resource-demanding patients in the categories mentioned that psychiatry has developed and gained the status of an essential branch of medicine. That is where it belongs.
Developments in recent decades, however, have led to an enormous expansion of the illness concept and an enlargement of the psychiatric jurisdiction. An increasingly large proportion of society's psychiatric resources is seeping over from the truly ill to individuals with dubious diagnoses – to patients who in the past simply were not in psychiatry and who should hardly be there. This takes place through the constant creation of new diagnoses, which through media suggestion leads people to perceive what are in fact normal human reactions as psychiatric.
Declaring healthy children sick
From around 1990, it became common to make psychiatric diagnoses on children with different forms of adjustment difficulties, which were assumed to be caused by congenital brain damage or abnormal brain development. This development was initially positive, since there are children with congenital and severely disabling adjustment problems. With new neuropsychiatric insights, these problems were given more reasonable interpretations, and the children were given more adequate support. In particular, this development meant a radical rethinking of autistic constitutions. As late as the 1980s, these constitutions were blamed on the children's mothers having been emotionally cold – a heart-rending indictment of parents in their most difficult crisis.
This scenario has gradually taken on a cynical aspect: hope for the parents lies in their child being declared psychologically disabled and brain-damaged, since such judgements have become tickets to help for low achievers. One article which drew considerable attention was published in the national daily Dagens Nyheter on 20 March 1997, and contributed to a lively and lengthy debate in Sweden, which is still continuing. In the article, Gothenburg professor Christopher Gillberg together with a school doctor Sophie Ekman claimed that one tenth of the young population is suffering from "considerable neuropsychiatric problems". They asserted that the neuropsychiatric condition, overall, probably presented "the greatest threat to public health in Sweden".
In order to form an opinion on the neuropsychiatric expansion, one must reflect on the nature of individual psychological characteristics and on the consequences of social development. For practically its whole existence, humanity has lived in a hunter-gatherer state, a nomadic existence in relatively small groups. Such life conditions formed the background for the development of all kinds of human psychological differences, including gender differences – differences which have not disappeared. Until a few centuries or millennia ago, people lived in types of environment and social conditions radically different from modern society.
Some remnants of the "Stone Age behaviour" make adjustment more difficult in modern society. Therefore, our need, for example, for reckless risk takers is limited, at least in times of peace. Several of the capabilities that are particularly developed among women, such as social and linguistic capabilities, on the other hand, have increased in importance – due to increased congestion, theoretical schools, demands for study discipline and negative attitudes to the use of violence in handling conflicts.
Even in the Stone Age, there were, naturally, mental constraints of all kinds which today lead to neuropsychiatric diagnoses, but at that time they were hardly critical disabilities. In small groups, with everyday life filled with practical work, limited linguistic and communicative skills were not a major problem. Motorically hyperactive boys were not required to sit still together with girls and listen attentively in classroom situations. Latent reading and writing difficulties existed, but no one could know anything about this.
Various types of psychological properties, which have always existed, are now perceived as neuropsychiatric conditions – that is to say, psychological abnormalities. It is principally boys who are given the diagnoses. Individuals with weak emotional development, limited capacity for social interaction, atypical communication and eccentric interests are diagnosed as having Asperger's Syndrome. Demarcation with normality is here so diffuse that an increasing number of individuals risk being included. It is a sign of the times that Albert Einstein, Ludwig Wittgenstein, and several other celebrities have posthumously been given the diagnosis.
Children who owing to attention disorders and concentration difficulties cannot meet school requirements have been identified as an especially large neuropsychiatric group. It is asserted that several per cent of all boys suffer from this condition, DAMP (Deficits in Attention, Motor control and Perception), a Swedish diagnosis for such adjustment problems, or from ADHD, a more generally used name for the condition with slightly different content. Reading and writing difficulties, dyslexia, also sorted under the group neuropsychiatric conditions, and a further number of variants belong here, such as Tourette's Syndrome.
Psychological properties become neuropsychiatric when they are classed as abnormalities and given diagnoses. The term "condition", through its elasticity, is central to the activities. It does not directly say anything about what is healthy or well, normal or abnormal. The sluice gates are thereby opened to diagnose individuals who are both healthy and normal. All that is required is to demonstrate a difficulty which is included in the growing group of neuropsychiatric conditions.
However, diagnoses are in fact perceived as designations for illness. The picture that is passed on to the public, including the parents of affected children, is unequivocal: the neuropsychiatric conditions are psychological deviations with their origins in congenital brain damage or brain damage acquired at an early age. A small proportion of the neuropsychiatric conditions is due to known illnesses, identified genetic defects or demonstrable brain damage. In certain cases, behavioural disturbances are so grave that individuals would not have a chance without extensive support to adjust to any society. However, an increasing number of cases are in a grey zone where psychiatrists can only assume some form of abnormal brain function.
The development and complexity of the brain
Against the background of the fast development of neuroscience, neuropsychiatric diagnoses increasingly appear simplified to an unrealistic degree, which can be illustrated with the following example. In a single normal human brain, there are approximately 100,000 million nerve cells, which perform mental work in stupendously complicated interaction. To this must be added a vastly larger number of glia cells, which are important for the brain's structure and metabolism. The nerve cells are formed before birth and are generated at breathtaking speed. Throughout the foetal stage, an average of 250,000 nerve cells are formed each minute. When their divisions cease, they move on to genetically pre-programmed destinations. Once at their target, the nerve cells are supposed to take position in the right places and form synapses – links with other nerve cells.
In the cerebral cortex (the "bark") of the adult brain, the nerve cell is in direct contact with approximately 10,000 other nerve cells. The nerve cell sends out signals via a special extension, the nerve fibre. The total length of nerve fibres in a completely normal brain corresponds to the circumference of the earth several times over. The number of theoretically possible synapses in a single brain is estimated to be greater than the number of atoms in the entire universe.
It is self-evident that the formation of the brain can differ considerably from person to person. It is governed principally by hereditary factors which vary between individuals. Of the approximately 30,000 human genes, it is estimated that half exist to form the brain and maintain its functions. Things also happen along the way. Illnesses, disturbances to the metabolism, stress and drug abuse by a pregnant woman can affect the development of the foetal brain. In addition, the foetus itself can be affected directly by injury, illness or the effects of random factors with consequences to the formation of the brain.
Variations in the normal construction of the cerebral cortex can be observed with the naked eye. The differences at microscopic level are probably enormous. It is probably a question of the presence or absence of thousands of millions of nerve cells or the existence or lack of trillions of synapses. In addition, there are all the variations in the development of the brain due to experiences after birth.
As a consequence of its extreme complexity, one must expect the formation of the brain to vary much more than the formation of every other organ, whose differences in general we know quite well. A consequence of this is in turn that the main product of the brain, the mind, must vary enormously – something which we can constantly observe in our fellow human beings. However, the majority of all the more or less extreme mental properties are a consequence of natural variation. They cannot, as at present is done through the term neuropsychiatric condition, be considered signs of disturbed brain functions. Still less can they be interpreted as expressions of illness or brain damage.
To be successful, systems for psychiatric classification must delimit at actual intersections in the repertoire of mental conditions. However, the modern rules of psychiatric diagnostics do not answer the basic question of what behaviours in fact are abnormal or pathological. In addition, its rough categories are not in harmony with increased knowledge about the complexity of the neuropsychological system.
The psychiatric diagnostic system forms the core of a branch of medicine. For that reason people are led to believe that neuropsychiatric conditions are unnatural or pathological. However, basic personality traits, with strengths and weaknesses, have principally natural, non-pathological causes, due to the incredible complexity of the brain's construction. Individual psychological difficulties are linked to the fact that we must manage to adjust to increasingly complex and changing environments – with new demands for which evolution has not always equipped us.
Of course, children who suffer from learning problems and adjustment difficulties have help needs and a right to help. The criticism of child psychiatry diagnostics addresses something else completely: the tendency of society to accept psychiatric solutions to problems which are rather of a social and political nature. Neuropsychiatric diagnoses have certainly brought progress for some children with grave congenital adjustment problems. However, opportunism and lay influence have led to over-diagnosing which risks bringing ridicule over the activities. Experts in child neuropsychiatry conscious of their responsibility should react when something as sensitive as their diagnostics is side-tracked and begins to become a matter for Everyman. Rational people in general should be alarmed by the development where an increasing number of their fellow human beings are declared abnormal and given psychiatric diagnoses.
Healthy adults declared sick
Adult-ADHD. In the wake of neuropsychiatric successes, an increasing number of adults are constantly being prescribed investigation with a view to one or other of the new diagnoses, especially suspected ADHD. A proportion of this patient group has already been in contact with psychiatry, but there is a level of dubious recruitment. Individuals who are apparently normally/acceptably adjusted to their social and professional environments, and who have had no previous contact with psychiatry, are now to be neuropsychiatrically diagnosed.
A few years ago, the psychosis and rehabilitation clinic at the Akademiska Psykiatricentrum (Academic Hospital Psychiatric Centre, Uppsala, Sweden) set up a team for investigation and treatment of adults with ADHD problems. After modest and hesitant beginnings, activities have grown fast, and at the time of writing, April 2004, the "ADHD team" has 10 employees: two doctors, three psychologists, two counsellors, an occupational therapist, a nurse and an office clerk. Two employees work full-time, the rest part-time. The ADHD team has the capacity to investigate only 20 to 30 cases a year, and approximately 30 patients are on the waiting list. Most of the clients have not previously been psychiatric patients.
All adults diagnosed with ADHD in Uppsala are treated with Ritalina® (an amphetamine preparation), which for each individual case requires special permission from the Medical Products Agency. Due to restrictions concerning the medication, the ADHD team must report extensively, contributing to the unusually time-consuming and expensive nature of the investigations. Employees freely admit that the investigation procedures would be considerably simplified if it were not for the administrative restrictions surrounding treatment with Ritalina.
At the neighbouring clinic, for care of patients with drug abuse problems, there is another, as yet totally separate, ADHD project. It is intended that the two Uppsala units of psychiatry for adult ADHD are to co-operate, and perhaps merge. The extent of the ADHD activities described here will therefore probably increase.
Twenty years ago, few had heard of ADHD, and the diagnosis was long perceived as a tool solely in child psychiatry. Despite the unclear nosological status of the diagnosis, interventions for diagnostics and treatment of ADHD adults alone constitute by far the most extensive investigation activity in psychiatry in Uppsala.
Burnout. Long-term sick leave (at least 60 days) in recent years has increased dramatically in Sweden, especially among middle-aged women, and most of the increase is related to mental problems. Through new psychiatric illness terms, people are encouraged to feel ill in new ways – while there is no reason to suppose that the general state of health should have deteriorated. Even if "burnout" is not yet to be found in regular psychiatric diagnostics – signifying mental fatigue (in working life) – it is a psychiatric concept.
The diagnosis was introduced in 1997 in the Swedish publication Klassifikation av sjukdomar och hälsoproblem ("Classification of Illnesses and Health Problems") and is probably the worst cuckoo in the nest of the Swedish social insurance system, since there are no rules for how to assess it.
The perception has quickly spread that a person who "feels unwell" is burned-out and has the right to a diagnosis accompanied by sick leave – especially if the person can demonstrate that the mental downturn has to do with the demands of working life. Burnout enables time-out from the drudgery and responsibilities of working life. Many doctors have spoken of how difficult it has been to ward off the diagnosis. This is because it is not based on any objective criteria, but in practice the diagnosis is made by the patients themselves – with a demand for sick leave. In recent years, there has been a lively debate over this reason for sick leave. It is probable that the burnout boom has passed – probably to be replaced by some related diagnosis, for example "fatigue syndrome", which indeed is in use.
PTSD (post traumatic stress disorder) was introduced in 1980 in DSM III as a diagnosis for adjustment problems caused by unpleasant experiences earlier in life. The diagnosis was originally brought to the forefront to further the insurance-related interests of American Vietnam veterans. Initially, the criteria included memories of or associations to the traumatic event that recurred in thoughts or nightmares. However, the requirement of a clear connection between mental suffering and the triggering experience has become less stringent. The diagnosis PTSD can be made also if the affected person does not have thoughts or dreams about the traumatic event that is assumed to be the origin of the mental disorder – and even if the patient cannot remember the event at all. It is considered that the memory of the psychic trauma can be "suppressed".
Soon, PTSD began to take on more sweeping applications, especially in work with women and children who had been the victims of different forms of mistreatment. It was supposed in particular that an important reason for women's mental adjustment problems could be the suppressed memories of sexual assault or incestuous relationships which the patients had been through in their childhood. This has caused a large number of psychologists therapeutically to support women with a view to their eventually being able to bring forth to a conscious level the memory of the awful experience they have been through – memories whose authenticity in many cases has been questionable.
Disaster psychiatry is intended to prevent PTSD after the experience of disasters. It went through an early upswing in Sweden in connection with the plane crash in Oskarshamn in 1989 and became recognised as an important branch of medicine after the ferry Estonia sank in 1994, with the loss of over 850 lives, mostly Swedish. As usual in psychiatry, the applications were broadened, and now there are crisis teams prepared for practically every emergency where people are suddenly affected by traumatic events, for example when a colleague has died at work. A related phenomenon is the psychiatrization of immigrants' adjustment problems, which are almost routinely interpreted as PTSD, i.e. as reactions to traumatic mental experiences.
The expansion of disaster psychiatry was illustrated soon after the terrorist attacks in the USA on 11 September 2001, when Aktuellt, a news programme on Swedish public service television, presented an indignation report. A leading psychiatrist in the studio declared that Swedes suffered mentally after the events in Manhattan, and that he found it deplorable that society did not provide sufficient psychiatric expertise. The viewers were encouraged to demand professional help if they felt unwell.
Alongside the modernisation of society, new psychiatry is developed. Changes in family formation, fewer children, more sole occupants, and relatives at long distances from each other have attenuated social networks, where individual crises are traditionally addressed. Many decades of Swedish social engineering have caused a drift of responsibility away from the individuals themselves to society – which has created acquired helplessness. The characteristic inventiveness of psychiatry is due to several unfortunate circumstances. Psychiatry finds itself in constant media interaction with surrounding interests in society. This means that diagnostic innovations quickly reach, and are absorbed by, lay persons, and that groups outside psychiatry can bring about the creation of new psychiatric terminology and practices. Backed up by pharmaceutical companies, patients' associations are developed or strengthened, and function as influential lobby groups that act as proponents of different diagnoses and their specific treatments.
Psychiatry's notoriously weak knowledge base provides a hotbed for a number of schools of psychiatry that are intellectually incompatible. This may signify plurality, but, above all, it has contributed to sectarianism, which hinders or prevents sensible communication between the different camps in psychiatry. The academic burrow in psychiatry gives plenty of opportunities for flighty whims to quickly meet a response and to be put into clinical practice. Follies are constantly repeated: it is seriously believed that the diagnoses refer to pathological conditions which really exist.
In the past, there was stoic realisation that it was in the nature of human existence that life can be – and often is – difficult and mentally burdensome. However, attitudes to how heavy a burden should be considered bearable change with social development. Psychiatry, with its inventiveness, undoubtedly plays an important role here. It is the existence of the diagnoses rather than increasing ill-health which above all contributes to Sweden's rising rate of psychiatric ill-health. Socio-economic circumstances and capacity for adjustment vary in an unfair way from person to person, and this is the main reason why so many "feel unwell". However, the capacity of society through healthcare interventions to rectify this situation – if one may say so – is severely limited.
Odd perceptions of what might reasonably be construed as mental ill-health in the long run lead to over-exploitation of the resources of healthcare and the social insurance system. Uncontrolled application of new diagnoses, which encourages more and more people into the fold of psychiatric ill-health, is undermining already weak confidence in psychiatry.
Ordinary forgetfulness becomes an illness
At present, a diagnostic yarn is being spun, which risks making an ordinary bad memory into the next major widespread disease. The new diagnosis, which is Anglo-Saxon in origin, is MCI, mild cognitive impairment. If the worst comes to the worst, it will mean that hundreds of thousands of Swedes will associate benign forgetfulness with dangerous ill-health – ultimately a precursor of Alzheimer's Disease.
About twenty years ago, the increasing proportion of elderly people in the population led to an increased focus on dementia illnesses. It was discovered how common Alzheimer's Disease is, and that the risk of being affected increased exponentially with age. This is a well-defined disease – with a characteristic course and special clinical signs, as well as a special type of brain changes. It is, in addition, hereditary by nature.
Growing awareness of the disease among the general public increases the tendency to associate even benign forgetfulness, for example, the kind that is related to depression or stress, with the beginnings of Alzheimer's Disease. In addition, family members feel natural anxiety since the disease is known to be hereditary. This understandable anxiety leads to oversensitivity to symptoms and signs of forgetfulness. An increasing number of relatively young people come for examination because they think, or someone close to them thinks, without real reason, that they have been afflicted by Alzheimer's Disease.
Alzheimer's Disease is considered to constitute half of all dementia cases, and an estimated 10 per cent of all 80-year-olds suffer from it. It is therefore interesting to pharmaceutical companies, and major efforts are made to develop medicines which stop or slow the course of the disease. Progression-slowing drugs have been available since the 1990s, and they generate large sales. Medicine costs are rising, partly because an increasing number are diagnosed due to more active diagnostics – and increasingly early in the course of the disease; partly because new preparations are continually being introduced.
The public perceives existing Alzheimer's preparations as preventive medicines rather than progression-slowing drugs. The objectives for the medications are, however, modest. Literally every patient receiving treatment is expected to suffer from increasing dementia – but hopefully at a slower rate than they would have without the treatment. The usefulness of this kind of medicine is of course difficult to evaluate. The success of the preparation depends on marketing rather than on positive therapeutic effects. Sales benefit if forgetfulness is developed into a general public health problem. This is stealthily happening.
This is because Alzheimer's researchers are becoming increasingly interested in cases of early memory loss, which is a legitimate research mission. In order to understand a disease, it is of central importance to know its earliest manifestations. Therefore, institutions have begun to set up "memory clinics", in principle for all individuals worried over difficulties in remembering things. However, the problems for which patients seek help are often benign forgetfulness which can trouble everyone occasionally.
With the knowledge that forgetfulness is the main manifestation of Alzheimer's Disease, the idea is spreading that one should have oneself tested as early as possible if worried about memory loss. For this purpose, special psychological tests are developed, and many of those tested will receive diagnostic proof that they really are suffering from memory loss, albeit moderate. Those who become enmeshed in a diagnostic yarn are given the diagnosis MCI, minor cognitive impairment. The popular name for this, "Alzheimer light", has become a common term for ordinary forgetfulness. In a TV appearance in connection with a scientific symposium on MCI in Saltsjöbaden in summer 2003, a prominent dementia researcher confirmed that MCI is a kind of "Alzheimer light".
In the textbook Alzheimers sjukdom och andra kognitiva sjukdomar ("Alzheimer's Disease and other cognitive diseases"), written by four professors headed by Jan Marcusson, a chapter is devoted to MCI. The authors write that it is not known for certain how many people develop or suffer from MCI, "since it has not been determined what inclusion criteria one should use or what is 'normal'". Further: " most conditions with mild cognitive symptoms not due to mental illness, confusion or dementia can be included in the diagnosis group (= MCI)".
Marcusson and his colleagues thus frankly admit uncertainty both over how to apply the diagnosis MCI, and even over what is normal in this context. Such circumstances do not however prevent the authors from banging the drum for MCI. The diagnosis which encompasses "most conditions with mild cognitive symptoms" evidently includes annoying but benign ordinary forgetfulness. So nobody can feel safe.
The perception is spread, not only that memory loss is a far more common problem than one might have suspected, but also that it is a pathological problem that must be taken seriously. Leading dementia researchers have also begun to emphasise the frightening association between memory loss, for example, in 50-year-olds and Alzheimer's Disease. It is put forward that what to date has been taken to be the harmless forgetfulness of the middle-aged can be early manifestations of Alzheimer's Disease, which will take on more serious forms in, say, 10 or 20 years.
As has been shown, MCI diagnostics is an activity which is difficult to delimit and which is debatable. Through its existence in the borderland between normal and pathological, the activity demands a combination of first-class test methodology and unusually good clinical judgement – properties that hardly characterise the examinational routines now being launched. Examinations that lead to the diagnosis MCI demand resources, since the patients need to be followed up through repeated testing. In addition, it is in the nature of things that also a large number of individuals who do not qualify for the diagnosis must be re-examined. An initial release from suspicion of MCI does not exclude the possibility of increasing memory loss, which can become apparent during re-examination. In practice, the MCI concept will then lead not only to those receiving the diagnosis being followed up, but also to those who do not receive the diagnosis being given opportunities for re-examination.
The reason why it is possible to persuade healthy people to believe that they are suffering from Alzheimer's Disease is that it is characterised by symptoms which – in their mildest forms – appear also in completely normal individuals. To give a few examples, Alzheimer patients forget names or things that have happened or been said, and they forget where they have put things. The problem is no doubt familiar to many. Benign forgetfulness of this kind is something with which we must live, and regardless of how frustrating it can be, we can frequently and casually joke about it.
Now, however, people are encouraged to reflect over, and risk becoming fixated on, ordinary forgetfulness, and to associate it with disease. Healthcare resources are mobilised, especially for very early diagnoses of Alzheimer's Disease. We do know that 10 per cent of all those who reach advanced old age will be affected, but at the present level of knowledge we cannot determine in advance who will develop the disease.
The diagnostic situation would change radically if we discovered a reliable biological marker for Alzheimer's Disease. It would then be possible through samples taken from each individual to determine with certainty whether the individual was predisposed to or suffering from the disease. However, no such diagnostic breakthrough has occurred.
Naturally, medical research in general is something positive – but hardly when progress consists of the "discovery" of completely new health problems which several per cent of the population are assumed to have. It is quite improbable that so many should suffer from a disease which has not already been observed and given a name. New "major" diagnoses should be viewed with suspicion; especially since psychological adjustment problems form a hotbed for diagnostic innovation. They belong on the fringe, where the knowledge base is so uncertain and the boundaries between healthy and ill are so vague, that disease can be called forth without the presence of ill-health.
The medical history of the last few decades should have taught as a lesson. Psychiatry has launched a plethora of diagnoses discussed in this essay, which include PTSD, MBD, DAMP, and ADHD. They are only vaguely defined and difficult to handle in practice, which means that healthy individuals are declared sick, or have their individual problems inadequately explained. All new psychiatric diagnoses tend to be overused, and in the case of MCI, with its nebulous nosological status, the way is paved for abuse.
Since we still lack effective treatments, the human price would be high if the diagnosis of Alzheimer's Disease were made much earlier in the course of the disease than is done today. Individuals affected, not yet particularly troubled by memory loss, would have their inevitable and painful decline spelled out to them. Others would be frightened on completely irrational grounds, because the diagnosis was wrong.
The intensified interest in memory loss brings with it a new diagnostic trap, which is linked to pharmaceutical product development. When sufficient numbers are concerned about failing memory and have been diagnosed with MCI – then the pharmaceutical companies will introduce memory pills. To be a commercial success, such a medicine will not need to have any remarkable effect on the memory. The main thing is that the side-effects are judged to be harmless, and that one can convince the public that the preparation protects against forgetfulness.
The strength of pharmaceutical market forces is illustrated by the triumph in Sweden of the antidepressant SSRI preparations. In the last few years, costs for that group of drugs have burdened Swedish medical insurance more than any other type of medicine. They are prescribed at a rate that corresponds to anti-depression treatment of 500,000 Swedes – about 6 per cent of the entire population.
In the light of our knowledge of the pharmaceutical market forces, there is no reason to doubt that the pharmaceutical companies yet again can enjoy success. Everyone forgets occasionally, and it is certainly possible to persuade the public that this episodic forgetfulness is a sign of illness. Neither should it be difficult to convince people who are frustrated by forgetfulness that it is wise to take memory pills – if for no other reason than to be on the safe side, before it all develops into really troublesome memory loss, perhaps even into Alzheimer's Disease. Without necessarily bringing any benefit, approved memory pills would find an enormous market, comprising in principle everyone of middle age and over. In addition, this would be medication that one should never cease to take.
The doctors' Hippocratic Oath is often summed up with the words cure, alleviate and comfort. It can hardly be in keeping with a project which impairs people's quality of life with the threat of a "disease" like MCI, against which at present one has no chance to protect oneself. It is not reasonable to give priority to ordinary forgetfulness in a tax-funded medical care system, in which one is forced to make agonising decisions to exclude genuine health problems which were previously treated. Finally, there is a risk that MCI will turn out to be yet another Trojan horse in the Swedish medical insurance system.
In conclusion
The commonest argument for the new psychiatric diagnoses goes something like this: "These diagnoses concern people who have adjustment problems or suffer mentally and the purpose is purely to help the afflicted." Those who express doubt about the diagnoses run a major risk of being accused of wanting to refuse suffering fellow human beings the help which they need. This cannot constitute a valid counter-argument, since the criticism is at a completely different level. A single psychiatric diagnosis may be harmless or perhaps in some sense favourable to the individual in question. However, the way in which psychological difficulties are explained and treated is no trivial matter particularly if the explanations are inadequate.
This is because psychiatric diagnoses lay scientific claim to saying significant things about human nature and adjustment problems. They do not merely have major economic consequences; they also have a significant influence on our culture and our perception of reality. There are plenty of good reasons to question the rationality of the psychiatric boom which we are at present witnessing. Reason is evidently in short supply in the face of the flood of diagnostic innovations. Why is it that people and society are prepared so uncritically to accept diagnoses which quite recently they have never heard of, and how can this development occur so fast?
I believe that one significant explanation is the unreflecting and rapid way in which research can be initiated. Practically every psychiatric idea seems to be a possible object for scientific study, and the construction of the new psychiatric diagnoses guarantees that there is easily available empirical material with which to work. The diagnoses are based on lists of criteria which to some specified extent must be fulfilled. The constellations of criteria make it clear from the outset that there are "sufficient" patients who fulfil the inclusion criteria – especially since there is seldom a precise stipulation of the degree of severity of the different problems that is required for inclusion.
One would have no problem in identifying a suitable group fulfilling the criteria for conditions such as PTSD, ADHD or MCI; and, once this is done, in applying the usual empirical approach which is customary in medical research. How is the epidemiology, what are the causal mechanisms and manifestations of the disease and how can the condition be treated? Scientific literature rapidly appears dealing with the diagnosis, which suddenly has an air of being academically established, and soon the proponents consider that there is solid evidence that the diagnosis really describes an existing disease, which must be taken seriously. By then, it may be too late to raise objections, because the scene has suddenly changed. The diagnosis sceptic is fairly powerless against the scientific establishment, which is armed with data and theories – and in general has the additional economic backup of companies with a commercial stake in the diagnosis.
Society really needs psychiatry for the important work with the weakest patient groups – the mission that justifies the existence of this branch of medicine. However, we need to be wary of psychiatry, which declares practically every form of unpleasant mental condition and reaction to be pathological – even normal expressions of human life. We must also be especially careful of psychiatric research, which at an accelerating rate is shaking our perceptions of what it means to be human and to live in a changing society.
Håkan Eriksson is lecturer and textbook author in neuropsychology, and has a position at the Psychiatric Division of Uppsala University Hospital, Sweden.
Homepage: hakaneriksson.se E-mail: hakan.eriksson@akademiska.se
References
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