ADD for All
On Big Pharma, overdiagnosis, and the questions unasked about medicalization
What is diabolical about the present situation is that whenever we want to refer to a realm outside medicine we find that it has already been medicalized.
We live in a medicalized society. We have grown accustomed to hearing that yet another behavior, emotional state, temperament, or bodily experience — some feature of life not previously regarded as a syndrome or disorder or addiction or risk factor — will henceforth be defined and treated as a medical problem. Those unhappy with their shyness or fear of criticism may be diagnosed with social anxiety disorder. Women not sufficiently interested in sex may be diagnosed with female sexual interest/arousal disorder. Kids who do not pay adequate attention to their studies may be diagnosed with attention deficit hyperactivity disorder. (One fifth of America’s twelve-year-old boys have been.) Even homelessness now has a diagnostic code.
The number and scope of pathologies grows ever larger. And while some of them surely do capture cases of severe dysfunction, many are what we might otherwise consider normal, even if painful, struggles of life, or just part of human variation: mild inhibitions on life plans, social role conflicts, unpleasant emotional experiences, normal bodily processes. The term “medicalization” implies the capture of these kinds of things. As the psychiatrist Thomas Szasz once observed, we “do not speak of the medicalization of malaria or melanoma.”
In theory, it should also be possible to demedicalize features of human experience, much as we can decriminalize certain acts. Demedicalization, however, virtually never happens, even when all we mean by this is raising the diagnostic thresholds so as to reduce the sphere of human functioning deemed clinically relevant.
Why not? Why might the domain of pathology be constantly expanding, while the reverse, a contraction, almost never occurs? I want to venture an answer, one that centers on our ever more shrunken and impotent conception of ourselves, of who we are and what we can be.
The term “medicalization” first came into widespread use in the 1960s — scholars often credit a 1968 article in the International Encyclopedia of the Social Sciences as originating the term, although more obscure examples can be found earlier. But the process to which the concept refers was first discussed in the 1950s among scholars concerned about the growing tendency to link crime and delinquency to mental disorders and illnesses. Medical sociologists in the early 1970s then widened the focus beyond psychiatry to the whole of medicine. Since then, sociologists, anthropologists, historians, physicians, bioethicists, and others have documented the steady transformation of an ever wider range of human experience into disorders, illnesses, deficiencies, or targets of medical intervention.
Most of the research has centered on case studies that can be sorted into four areas of medicalization:
The sheer extent of these transformations has prompted leading medicalization theorist Peter Conrad to speak of the progressive “pathologization of everything.”
The concept of demedicalization also has a long history, but there has never been a consensus on its meaning, and its use has varied widely and confusingly. For one thing, there are in fact run-of-the-mill cases of what might be considered demedicalization. Diagnostic categories regularly get eliminated from the Diagnostic and Statistical Manual of Mental Disorders or DSM, the main guidebook used by clinicians.
But normally, diagnostic categories disappear only because their symptoms are divided up and subsumed under other conditions. The nineteenth-century condition of hysteria, for instance, was divided into the then-novel diagnoses of “dementia praecox” and “manic-depressive psychosis,” later known as schizophrenia and bipolar disorder, respectively. More recently, there was a widespread clinical practice of diagnosing and treating children with a form of bipolar disorder — though not recognized in the DSM, clinicians called it “pediatric bipolar.” The authors of the newest, fifth edition of the manual sought to quell this hot debate by creating a new category, “disruptive mood dysregulation disorder.” By providing a new category, basically a temper tantrum disorder for non-toddlers, they sought to steer clinicians away from diagnosing children as bipolar, tacitly delegitimizing the “pediatric bipolar” category.
According to Conrad’s definition, demedicalization requires something stronger than any of this. “For demedicalization to occur,” he writes, “the problem must no longer be defined in medical terms, and medical treatments can no longer be deemed appropriate interventions.” This definition has the advantage of clarity, but it sets the bar too high. Rather than describing cases where a condition is recast, it means that medical professionals come to believe that some condition never existed at all, that the entire diagnostic category was a mistake.
That categorical rejection is what took place with homosexuality, which used to be included in the DSM, but after a political struggle was removed in 1973. Likewise, masturbation was long ago regarded as a disease.
Another example is “masochistic personality disorder,” a term arising from Freudian psychoanalysis to describe people who seek out abusive relationships, suffering, or physical punishment. After it had been used by many clinicians for decades, the third edition of the DSM listed it as a proposed diagnostic category under the name “self-defeating personality disorder.” But after a strong campaign in the 1980s led in part by feminist psychologists, and including media coverage, protest demonstrations, and threats of legal action, challenging its validity on the ground that it amounted to victim-blaming, it was successfully blocked from becoming a full diagnostic category, and mentions of it were deleted from the fourth edition.
But that is almost the end of the list, and it is easy to see why the process is rare. Demedicalizing a condition involves a wholesale rejection of the very category, a move unlikely to occur without some powerful pressure from outside medicine itself.
A more realistic way we could imagine demedicalization happening is not by completely eliminating a category but by making its diagnostic criteria more stringent. Medicalization refers not just to the growing number of new categories of disease, disorder, and risk but also to their expansion to an ever wider scope of human characteristics, states, and experiences. Conrad, for example, who has long studied ADHD, suggests that
it is certainly possible that a small proportion of children with a diagnosis of attention deficit hyperactivity disorder may have a discernable neurological problem, but the identification and diagnosis of ADHD goes far beyond these few children and includes a huge number of children with no identifiable neurological disorder.
The problem, on this understanding, is not so much the category itself as the set-points for the diagnostic criteria — a view echoed by David Kupfer, who chaired the task force overseeing the writing of the DSM-5 and said that the previous edition’s thresholds for an ADHD diagnosis were “too low,” causing an “unreal” epidemic.
Demedicalization, then, might be thought of as the process of raising the diagnostic thresholds for a condition so that it captures only serious and debilitating clinical cases. By this process, what the psychiatrist Peter Kramer once called “diagnostic bracket creep” would be reversed; cases sometimes referred to as “mild disorders” and “subthreshold syndromes” would be eliminated. The domain of pathology would shrink, and far fewer individuals would be subject to medical management.
But this reversal too appears to hardly ever happen. The solution to the “unreal” ADHD epidemic that Kupfer noted would have been to change the criteria for the diagnosis so that kids with mild “symptoms” are not diagnosed or treated. But instead the DSM-5 lowered the thresholds even further. The unreal epidemic got worse. More youth qualify for the diagnosis, which is now also skyrocketing among adults.
According to a 2016 paper by psychologist Nick Haslam, over the past sixty years
the concept of mental disorder has undergone significant expansion…. An increasingly wide assortment of psychological phenomena fall within the psychiatric domain and diagnostic criteria have tended to loosen over time, so that clinical presentations that would once have failed to reach the threshold of diagnosis now do so.
A similar relentless expansion, in diagnoses and risk factors, can be seen in other areas of medicine.
So, we’re back to our original question. Why does change seem to move relentlessly in the same pathologizing direction?
Over the years, scholars have offered a number of explanations for the rapid expansion of medicalization. Early on, some suggested that it was driven by the medical profession itself, from its ambition to expand into new territory. That idea, however, never fit the facts very well and gained little traction. In the 1972 paper “Medicine as an Institution of Social Control,” the sociologist Irving Zola argued that it would be a mistake to see medicalization as the “result of any professional ‘imperialism’” on the part of physicians. Far larger cultural and institutional forces were at work, in his view, especially the growing popular preoccupation with health. Others, such as social critic Ivan Illich, argued along similar lines that the medicalization crisis had deep cultural roots.
Most medicalization research has been in the form of specific case studies. This literature has typically been less concerned with theorizing about the larger cultural shifts than with identifying which parties have an interest, symbolic or material, in medicalizing a particular problem. If we look at studies of gambling disorder, or premenstrual dysphoric disorder, or even the ongoing redefinitions of hypertension (high blood pressure), we will find different actors and agencies pressing for the medical definition and treatment. In any given case, these might include lay advocacy groups, social movements, medical subspecialties, medical device and pharmaceutical companies, managed-care organizations, social service agencies, patients — or, as they are increasingly known to the health care industry, “consumers” — and others. The specific advocates for medicalization depend on the particular problem or condition, and often work hand in hand with the creators of new medical devices, diagnostic technologies, or medications. There is no one engine of medicalization.
These studies suggest that medicalization is a contingent process — each case has its own history and can be shown to be neither inevitable nor uncontested. As Zola argued long ago, there is no necessary reason, on either scientific or humanitarian grounds, that medicine should penetrate ever deeper into daily life and ceaselessly reinforce the “belief in the omnipresence of disorder.”
And yet, on the accumulated evidence of over a half century, what we see looks a lot like an inexorable juggernaut. And, if we widen the frame a little, we see the same pattern of harm inflation in related areas. Nick Haslam, for instance, has shown that not only mental disorder but many of psychology’s other concepts have also undergone similar changes. Concepts like abuse, bullying, trauma, addiction, and prejudice “that refer to the negative aspects of human experience and behavior have expanded their meanings so that they now encompass a much broader range of phenomena than before.” For instance, the meaning of “trauma” has expanded from a life-threatening experience to include an ever growing list of adverse life events, of less and less severity and including not just direct but also vicarious experience. The reading of novels is now among the potentially traumatizing activities, while the sphere of adverse events has grown to include brief, often unintended slights or “microaggressions.”
In the therapeutic domain of social service agencies, lay support groups, self-help writing and the like, we find an expanding discourse of victimhood and self-limitation. The number of ways to describe our vulnerability has multiplied, with newer categories such as codependency, emotional abuse, and many forms of behavioral addiction getting added to older ones such as rape and battering. Many further terms have been coined or reappropriated to name new types of oppression and injury, often forming the basis of politicized identities: fatphobia and thin-normativity, transphobia and cisnormativity, ableism and ablenormativity, systemic racism and white supremacy, and so forth.
Vulnerable though indeed we are, subject to many forms of harm, we may see in this trend of expanding victim categories an “invitation to infirmity,” complete with a script for the way people are to feel, experience, and express it, writes sociologist Frank Furedi in Therapy Culture. In many of these newer examples, harm is understood in primarily psychological terms. The effect is to identify more and more people as in need of solicitude and care, to continuously expand the list of groups and identities that fall under the protection of diversity, inclusion, and “at-risk” policies, and to extend the forms of treatment, rational management, and protection — from psychotherapy to psychiatric medications, from training in emotional intelligence to mindfulness exercises, from trigger warnings to speech codes and canceling.
In none of these related arenas, to my knowledge, is there a counter-trend — a snowballing of concepts about positive aspects of human experience, a more stringent definition of “harm,” or a psychology of self-governing activity, mutual aid, and freedom in interdependence. Even much of so-called “positive psychology” has really become a therapeutic program aimed at solving problems, largely deficits in determination and “grit” that hinder strategic success.
All pathology, all the time. Surely, something deep is at work informing and nourishing this relentless trend.
Some have argued for various benefits to medicalization: increased sensitivity to and institutional legitimation for a problem, greater willingness to provide services to those affected, removing blame and stigma, and authorizing less punitive means of social control. But there are deep and persistent ethical concerns with its incapacitating features, in addition to practical concerns with the safety and side-effects of clinical interventions. Three features stand out.
First, medicalization strips problems of their social context and makes their solution a matter of individual treatment alone. For example, when the destructive pursuit of gambling is medicalized, all the social and cultural factors that explain its emergence and its amelioration disappear, replaced with a language of a chronic, relapsing brain disease.
Second, medicalization narrows the boundaries for what is acceptable and expected human variation. Medicalizing low sexual desire in women, for instance, involves setting some baseline level of “natural” desire, deviation from which determines if a disorder is present. What counts as “natural” here is necessarily a cultural value, but is not acknowledged as such. And defining such baselines denies legitimacy to alternative ways to live, reinforces gender stereotypes, and generates subtle but powerful pressures to conform.
Third, and perhaps most insidiously, medicalization shapes the way people relate to themselves and others and interpret everyday experience. The continuous medicalization of physical distress, for instance, in which mild symptoms are reclassified as diseases, has actually reduced our capacity to deal with discomfort, vulnerability, and pain. In exploring the medicalization of “everyday suffering” in my book Chemically Imbalanced, I found that ordinary people have come to see themselves in medical classifications, and have adopted neurochemical conceptions of their struggles. These understandings in turn act back on them, not only influencing the type of treatment they receive but reshaping and distorting their sense of self and self-efficacy.
The cumulative literature shows that medicalization fosters a misshapen picture of ourselves. Yet despite this rich body of critique, its actual impact has been negligible. The critique doesn’t go deep enough. We would not be so strenuously and one-sidedly pursuing the “pathologization of everything” if we had not already suffered a profound loss of confidence in who we are and what we are able to be — a forfeiture of status that is a crisis of the spirit.
The philosopher Pierre Hadot writes of the “Promethean attitude,” an orientation of modern science, coming down from Francis Bacon, that reduces all of our distinctive qualities to mere surface manifestations of more fundamental mechanisms and processes. What we are as humans — body and soul — is nothing more than our bare animality.
Many developments contribute to the shrunken anthropology at work in the medicalization crisis, but I have argued elsewhere for the pivotal role of the Promethean orientation to nature, especially as we can see it heedlessly applied in behavioral science. This is the behavioral science whose pretension, Hannah Arendt argued in The Human Condition, is to “reduce man as a whole, in all his activities, to the level of a conditioned and behaving animal.” This is the sociology of Émile Durkheim in The Rules of Sociological Method, a “science of things” carried out in the “state of mind of physicists, chemists and physiologists,” conscious of penetrating into a world of “facts governed by laws.” This is the “astonishing hypothesis” that geneticist and Nobel laureate Francis Crick proposed when he wrote that “‘you,’ your joys and your sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behavior of a vast assembly of nerve cells and their associated molecules.”
Crick’s hypothesis is anything but astonishing. The idea that “the mind is what the brain does” is a conventional axiom of cognitive neuroscience. In this field, along with developmental and cognitive psychology, behavioral genetics, and other disciplines that influence the understanding of human mental states and psychopathology, the dominant way to explain conscious experience is with little or no reference to first-person experience and one’s own sense of self. In these approaches there is no place for meaning. Free will is an illusion. Crick’s hypothesis would have been astonishing if he had proposed anything else — had he, for instance, proposed that our subjectivity is an aspect of reality.
A similarly mechanistic orientation also characterizes other social and behavioral sciences in which persons are replaced by categories and statistical averages, “reduced to relationships of cause and effect,” to quote Durkheim again, and powerless in themselves. All the meanings that might motivate human life are leveled and stripped away. The drivers of medicalization and of the psychology of harm are following the science, and that’s it.
Following right behind is the general public, which shares many of the deflationary and dehumanizing views that characterize cognitive and behavioral science. To be fair, most people are not such doctrinaire materialists as Francis Crick, believing that all higher-order psychological processes, such as thoughts and emotions, are completely explained by more fundamental biological processes. They still believe in some degree of freedom and self-determination. But they have also shown themselves to be quick adopters of medicalization.
For example, research has shown that in the decade between 1996 and 2006, the percentage of the public that “attributed major depression to neurobiological causes” jumped from 54 percent to 67 percent, and the percentage who believed the condition should be treated by psychiatrists from 75 percent to 85 percent. Over time, members of the general public have come increasingly to adopt a biological view of mental and emotional distress. They have embraced the idea that a diagnosis makes suffering “real,” rather than “all in their heads,” by somehow showing that it arises independently of volition and experience.
A physicalist anthropology can give no account of the world as we experience it, the one that helps us understand ourselves. It leaves precious little room for human freedom. To borrow from Jacques Ellul, “freedom becomes circumscribed and limited to a small area in which a man can move freely, like the owner of a garden who is free to do what he wants there but can’t go outside the gate.” Health, measured against group norms, is the one irreducible good. The point of therapeutics is no more than reducing adversity, restoring functioning, and promoting compliance. What enters our consciousness and shapes our self-understanding are deficits. Of ourselves, we can expect little.
Losing ourselves, our spirit, results in more and more pathology and little else.
We need demedicalization. All the pathology talk and drugs and therapies have not eliminated discontent and suffering. Relief has often come at too high a price — of relentless dependence on therapeutics and a diminished view of ourselves. Under pathological descriptions, the meaning-making that is relevant for a good life, for self-government, and, indeed, for health — questions of self, social norms, institutional arrangements, and much more — disappears because it simply cannot be raised or addressed in that language.
The psychologist Jonathan Shedler of the University of California, San Francisco reports that he and his colleagues have worked with many depressed patients over the years for whom “the idea that their difficulties could have meanings … was foreign to them” — the idea that distress or despair is tied to a person’s self-understanding and can therefore also be understood. The idea, writes Shedler, was apparently also “foreign to the doctors who treated their depression [with medication] previously, because no one even raised it as a possibility.” Medicalized idioms of distress often leave people trapped in a debilitating image of themselves, and alienated from their own experience — from relations with others, from their concrete circumstances, from their sense of heart, mind, and soul.
Many people feel and are learning this. A 2019 TED talk by the journalist Johann Hari, in which he argues against the overemphasis on biology and for the role of social disconnection in depression and anxiety, has been watched over ten million times. Shedler writes that even many therapists come to him for help, “wanting to be seen, heard, understood, and known.” But to help patients do so, we have to recapture the world of everyday experience and language from the confines of biological and psychological definitions, measurements, and interventions. These, too, can have their place. But we cannot begin to see what that place is until we bring our troubles back into the context of how we see and experience the world, as active participants in it, not just passive recipients of biological malfunctions or social hardships that act on us and in us.
We are not endlessly vulnerable and causally ineffectual observers of what happens to us. We are agents whose perceptions, thoughts, dreams, hopes, and beliefs also change the world. We need a science that incorporates those intrinsic qualities of our subjective experience that make the experience what it is, whether love or ambition or humiliation. We need a science that does not obscure the way that we interpret the world, the way we actively shape our understanding of it and of how we fit in, or feel that we don’t.
There is some progress. For instance, some philosophers have challenged the standard model in neuroscience according to which conscious experience neatly corresponds to observable brain states. Other philosophers, working in the phenomenological tradition, have challenged the third-person standpoint in our language of pathology — which assumes that we can understand suffering from the outside, as we do a physics problem — and have offered first-person alternatives and perspectives. And some developments in biology suggest a new appreciation for our social nature and the complexity of experience.
These are small steps in the right direction. Resistance to medicalization has a long and largely futile history. If we are to make real progress against this juggernaut — the continuing pathologization of everything — we need to begin at a more basic level, with a clearer picture of who we are.
Exhausted by science and tech debates that go nowhere?