I think that changes treatment choices, but I don't think it changes diagnosis. Plenty of people with cancer aren't affected by it (yet), but that doesn't mean they wouldn't be diagnosed with the disease.

DanBC is talking about the diagnosis of addiction (or indeed most mental illnesses), not diagnosing any disease.

For example, a patient would likely not be diagnosed with an anxiety disorder if symptoms did not have a marked effect on their day to day living.

This means that the disease model can not be said to be a tool used to enforce normative cognition or behavior, but a model to help decrease suffering.

Could you perhaps point me to a link? When I look at Generalized Anxiety Disorder, I don't see that one:

https://en.wikipedia.org/wiki/Generalized_anxiety_disorder#D...

"Excessive" is normative, there. And Oppositional Defiant Disorder seems quite clearly designed to enforce normal behavior:

https://en.wikipedia.org/wiki/Oppositional_defiant_disorder

And there are scads of articles critical of the way ADD is treated in the US, and specifically critical of how the diagnosis and medication are used to create classroom compliance. A teacher friend once substituted in a classroom where every single child was on medication. Given that the disease prominence is circa 10% and not all kids are on medication, either she should have bought a lottery ticket or there was some other factor than strict medical necessity going on there.

That's the problem with attempting to use Wikipedia as an authoritative expert source: it's not, and it's not what it attempts to be.

The part about marked effect on the life of a would-be patient would not be explicitly stated amongst DSM diagnostic criteria, as it is not a symptom of the illness in question, but rather something most mental illnesses have in common (i.e. a large part of the reason for viewing mental disorders as illnesses). However, the second sentence in the Wikipedia page on GAD (to which you linked) starts "This excessive worry often interferes with daily functioning".

Seeing "excessive" used in the context of the listed symptoms (DSM-5, your link), I'm hard pressed to view this as any sort of attempt to cull diversity.

As it is rather late in my timezone, I'm not going to go trawling for definitions, but if you're interested in reading more I can recommend NAMI, NIMH, the Mayo Clinic, etc. as good starting points.

As this isn't my area of expertise, I'm in no position to argue the specifics of ODD, but it has always been somewhat controversial [1], and particularly around the release of DSM-5, IIRC. But even if the whole world were to agree that ODD was poorly defined, or pehaps even concede that it was "designed to enforce normal behavior", it would not really say anything at all about neither the disease model, nor the field in its entirety.

Regarding ADD, the major controversy seems to be about possible overdiagnosis, and to some extent about relying too much on medications as opposed to therapy, AFAIK. I think there are several legitimate issues here, some of which are likely specific to culture, some to specific socio-economic contexts, others perhaps to the handling of ADD at large.

[0]: https://en.wikipedia.org/wiki/Generalized_anxiety_disorder

[1]: https://en.wikipedia.org/wiki/Oppositional_defiant_disorder#...

I'm not saying it's an attempt to cull diversity. I'm saying that when the disease model is all you have, it's easy to say, "there is a difference we don't like, therefore it must be a disease".

I think we both agree it happens, though.

Here's the DSM 4 criteria for GAD: http://behavenet.com/node/21591

> E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

I get what you're saying. We used to lock people up for many years just because they had an abortion at 17 and liked wearing yellow tights. But "Does this interfere with your day to day life? What do you want to change?" is an important part of diagnosis.

I think the problem I have with what you're saying is that I see, very often, people (mis)using psychiatric language to describe behaviour they don't like in other people.

Asshole boss? Sociopath.

Asshole employee? Asperger's.

Asshole with a gun? Psychopath. (Or, worse, psychotic.)

> A teacher friend once substituted in a classroom where every single child was on medication. Given that the disease prominence is circa 10% and not all kids are on medication, either she should have bought a lottery ticket or there was some other factor than strict medical necessity going on there.

Over-diagnosis is probably a problem, especially in the US. I don't know how diagnosis works over there. Over here it's probably too hard to get a diagnosis. But I'd be interested to know what a statistician would say about a class of pupils who were all on medication. We'd expect some clumpiness. And unless you know that 10% is evenly distributed (is there any reason to believe it is) you'd expect even more clumpiness.

I think we broadly agree.

What I'm pointing at is that the GAD criteria, as with the criteria for many diseases, is not, "Hey patient, is this a problem for you?" It's a judgment by the clinician over whether the impairment is significant. That's generally fine with wise clinical judgment and clear signals of illness. (E.g., there's little dispute over whether a broken leg is a problem.) But I think there are issues when things are only a problem for other people, or only a problem because other people are different. There I think applying the disease model can be mixed, both helpful (when it allows addicts to get the support they need) and harmful (when different people are treated as broken).

See, for example, the literature on medicalization of deviance: https://scholar.google.com/scholar?q=deviance+and+medicaliza...

This is especially problematic in the US because medicalization is not just socially convenient, but frequently profitable.

I also agree that people casually using diagnostic language is a problem. Indeed, I think it's closely related to the problem that concerns me, where people take traits that are helpful in some contexts and harmful in others and declare them to be diseases.

Regarding addiction, it would seem to me pretty obvious that it can be diagnosed even when the person doesn't admit that it affects their day to day living. I've met homeless drunks who swear to me that they don't have a problem with alcohol, and denial is a large part of addiction. And then there's the category of high-functioning alcoholics [1], where even outside observers can say it doesn't affect their day to day living.

[1] https://en.wikipedia.org/wiki/High-functioning_alcoholic

As I'm sure you realize, what is admitted, what is observed and what truly is are not necessarily the same.

Sure, which is my point. DanBC is claiming that the person with the nominal disease is the source of deciding whether it affects day-to-day life. I'm saying that's not the case. Other people get to decide whether it's a disease based on what's normal to them.

An example others brought up was that homosexuality was defined as a mental illness for many years. That's the same dynamic I'm pointing at.

That's not the case, though.

Clients are typically asked to assess to what extent the perceived symptoms affects their day-to-day life, any changes, etc., in addition to conferring with friends/family for their point of view on this. These are considered in addition to an absolute deviance from the "average spectrum" and diagnostic criteria.

I don't really think the pathologization of homosexuality is comparable to modern issues, as the reasons for this were very much informed by its historical context (its history as an immoral concept in christian/western culture, the state of psychology and psychiatry as fields at the time vs. now, etc.) in a way modern diagnoses aren't.

Also, according to Wikipedia [0], APA members were critical to homosexuality as a disorder at least from its inclusion in the first DSM.

[0]: https://en.wikipedia.org/wiki/Homosexuality#Psychology

What's your source for your claims? In the US, a lot of mental illnesses are medicated by general practitioners, and mental health insurance coverage is notoriously poor. That sounds like a great way to work, but it's not how I see the system actually working.

That you don't think pathologization of homosexuality is comparable is, I suppose, fine for you. I obviously do or I wouldn't have made the comparison. It's not like we don't have a historical context now as well; it's just a different context. In particular, the US has some very deeply culturally embedded notions about work ethic and willpower that are relevant to ADD and addiction treatment. That we corrected one mistake does not mean we corrected the general pattern of mistake.

Regarding the last bit, glad to know Wikipedia is now a reliable source when you're citing it in your favor.

There are sources abound [0-3]. The four Ds of abnormality [0] might be of particular interest. The point may be better explained (as I'll get back to) by textbooks and lecture notes, also available via Google.

That's the case in much of the world, which is indeed considered a problem, and may explain why medication may be overutilized. But the fact that the system's current practice is unfavorable, does not really say anything about the models used to understand mental illness.

ADD comes with certain dysfunction [0] (and perhaps distress) that homosexuality just doesn't, which is one of the reasons for my objection. While the field of psychopathology is certainly influenced by culture (as is readily acknowledged) I have yet to see any reasonable argument that addiction and ADD are pathologized on the sole basis of falling outside of "normal" experience. Additionally, the notions of work ethic and willpower that you mention might just as well be used to explain stigma towards the mentally ill – that they should just apply discipline and willpower.

Apropos of sources, I should very much like to see some that claim that ADD as diagnosis is inherently problematic, as opposed to it being abused as a consequence of certain cultures.

My gripe with your previous use of Wikipedia was not about Wikipedia itself, but the way it was used. By this I mean that while Wikipedia articles might contain misinformation, it is known to be surprisingly good, for the most part (though certainly no credible academic source). The problem, though, is that it will in quite a few cases not provide readers with minute details, standard practice or underlying assumptions – Wikipedia is an encyclopedia, not a practitioner's handbook.

[0]: https://en.wikipedia.org/wiki/Psychopathology#The_four_Ds

[1]: https://en.wikipedia.org/wiki/Mental_health#Perspectives

[2]: https://en.wikipedia.org/wiki/Mental_disorder#Classification...

[3]: https://en.wikipedia.org/wiki/Mental_status_examination

You seem to be arguing from the theory of mental health; I am talking about what people do in practice, and the cultural norms and views that shape the application of theory.

As to, "I have yet to see any reasonable argument" bit, I can certainly believe it. But I think that's mainly because you haven't looked. Plenty of people have talked about rampant overdiagnosis of ADHD in the US because putting everybody on stimulants makes classrooms easier to control. Overdiagnosis here means taking healthy but inconvenient behavior and pathologizing it. If people only have "dysfunction" in particular classroom environments with particular teachers, I think it's reasonable to suggest that what's dysfunctional is the environment and the expectation of universal conformity, not the people who are different.

It seems like we are mainly talking in circles here, and given that this is a topic on which I have paid attention to for a couple of decades and also have direct experience, your arguments from Wikipedia theory links aren't going to do much for me. Maybe we should stop now?

I realize what you're talking about.

The problem is that you talk about what you perceive as flaws in the disease model (theory) in your original post, and unsubstantiatedly claim that 'It posits one notion of normal and then divides everything into "normal therefore fine" or "different, therefore broken".', which is incorrect (as pointed out by DanBC).

If someone applies the model incorrectly, that doesn't undermine the model.

I have looked, and I have heard the arguments you are talking about, some of which I agree with (as you can see from earlier posts), but a common sentiment amongst some of these seem to be the almost conspiratorial belief that it is all based upon suppressing anything other than normal behavior.

I think it is more reasonable to suggest that the bar might be set too low when it comes to this diagnosis in the U.S., than it is to discredit the illness entirely because of what amounts to misdiagnosis. The subject is fraught with nuance.

As for the use of sources, there is clearly a discrepancy between our posts, though mine are admittedly often from Wikipedia.

If a lot of people use a model incorrectly, I think it's worth asking whether it's a bad model. E.g., "Good vs evil" is a popular model, but it leads to enough stupidity I don't think it unreasonable to say that is often applied without nuance.

If you would like a better source, take a look at Hallowell's work. His basic take is that ADHD is not a disease, but a trait:

http://www.drhallowell.com/add-adhd/

Of course, he's only a psychiatrist who specializes in ADHD and has written a half-dozen books on the topic, so I'm sure he's just lacking your subtle understanding of the perfection of the disease model. And probably a conspiracy theorist too; there are so many of those on the Harvard Medical School faculty.

And if you'd like more on how the disease model is misused, start with the literature on the medicalization of deviance:

https://scholar.google.com/scholar?q=medicalization+of+devia...

Sorry for the delay.

What you're talking about in this thread doesn't translate to applying the model "without nuance", but to wrongly apply the model or to not apply the model at all (since the model is not followed).

That's why I think your first post is wrong; the disease model does not claim that deviancy == illness. Rather, it claims that the identified problematic behavior is a result of a chemical/biological issue, and doesn't deal with definition of problems at all.

Also worth noting is that the purely biologic view isn't really en vogue any more. AFAIK, the biopsychosocial model is more popular.

In practice, it is valuable to view mental disorders as (i.e. not claim that they are) illnesses, one of the reasons for which you touch upon in your original post.

I have of course heard arguments like Hallowell's before, and I don't think that they're entirely unreasonable, although the gist of them can be applied to psychiatric diagnoses in general, seeing that all symptoms and traits can be said to exist on a scale/spectrum/continuum. Most literature I've seen readily acknowledges this (and notes pitfalls of other kinds, like being somewhat based on social norms). This is the one of the nuances I've previously alluded to.

As I think is quite clear from our exchange, positions like these are not the ones i disagree with, nor the ones I refer to as conspiratorial – that would be those that actually posit conspiratorial "theories", e.g. willful persecution of those outside the "normal" by practitioners, the powers that be, etc.

I'll refrain from commenting on your rude sarcasm and unreasonable assumptions, but know that cherry picking a source and appealing to its authority doesn't make for a convincing (nor logical) argument.

I'm also familiar with medicalization of deviance, though I don't see how this pertains to the disease model, as this kind of social control is possible (and has been performed) via a plethora of means.

P.S. Just came across an editorial [0] that deals with some of this that might be of interest.

[0]: http://bjp.rcpsych.org/content/191/5/375

I've certainly not intended to come across as rude, only as challenging your assertions. But I guess you'll read into it as you may.

And I certainly don't go attacking straw men before you've even had a chance to answer accusations (as in the rude sarcasm part).

I also note that you have yet to back up your original assertion that the disease model "posits one notion of normal and then divides everything into "normal therefore fine" or "different, therefore broken"', which is hardly surprising, as it doesn't deal with this definition at all.

Take care.