James J. Hughes

Deviance

UConn – October 28, 2009

Medicalization of Deviance Defining deviant

behavior as a medical condition

Medical-industrial complex defining us as sick to sell us cures

Doctors claiming social “problems”

Thomas Szasz:Mental illness is just deviance

Peter Conrad: ADD is just deviance

Medicalization Controversies Childbirth Shyness Aging Depression Addiction ADD/ADHD Aspergers Syndrome Unusual Bodies

Height, unusual genitals Sexual Behavior

ICD: What is a Disease?

World Health Organization’s International Statistical Classification of Diseases and Related Health Problems

ICD-9 (WHO 1977) – 17,000 codes ICD-10 (WHO 1992) – 155,000 codes ICD-11 (WHO 2014)

569.42 = rectal pain

Diagnostic and Statistical ManualManual of official diagnoses of the

American Psychiatric Association DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-III-R (1987) DSM-IV (1994) DSM-IV-TR (2000) DSM-V (2012)

History of ADD 1930s stimulants prescribed to treat “minimal brain

dysfunction” 1960s “minimal brain dysfunction”

“learning/behavioral disabilities” and “hyperactivity” Ritalin synthesized in 1950s, prescribed in 1960s DSM-II (1968): “Hyperkinetic Reaction of Childhood” DSM-III (1980): “ADD (Attention-Deficit Disorder)

with or without hyperactivity” DSM-III-R (1987): “ADHD” ICD-10: “Hyperkinetic disorders”

Diagnosing ADHD

DSM-IV criteria diagnose 4x more ADHD than the stricter ICD-10 criteria

DSM-based prevalence estimates between 3-10 percent of children and 3-6 percent of all adults1. Inattentive & Hyperactive-Impulsive

2. Primarily Inattentive

3. Primarily Hyperactive-Impulsive

Inattentive CriteriaSix+ for at least 6 months to a point that is

disruptive and inappropriate for age: 1. Often does not give close attention to details or makes careless

mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Often forgetful in daily activities.

Hyperactive-ImpulsiveSix+ for at least 6 months to a point that

is disruptive and inappropriate for age:

1. Often fidgets with hands or feet or squirms in seat.

2. Often gets up from seat when remaining in seat is expected.

3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4. Often has trouble playing or enjoying leisure activities quietly.

5. Is often "on the go" or often acts as if "driven by a motor".

6. Often talks excessively.

7. Often blurts out answers before questions have been finished.

8. Often has trouble waiting one's turn.

9. Often interrupts or intrudes on others (example: butts into conversations or games).

Treatment

Behavioral Stimulant

MedicationRitalin/ConcertaAdderallDexedrineStrattera

(atomoxetine - non-stimulant)

Diagnostic Creep Where do we

draw the line?

Conrad on ADD

Conrad’s 1975 “The Discovery of Hyperkinesis”

“The process of medicalization, often seen as humanitarian reform, has another side:

(1) expert control; (2) medical social control; (3) the individualization of social problems;

and (4) the depoliticization of deviant behavior.

Is ADD a Disease?

There isn’t a sharp, clear indicator but… Heritable Comorbid with Tourettes, OCD, epilepsy

and oppositional defiant disorder Clear differences between ADD brains

and non-ADD brains ADD kids are helped by stimulants,

while not all kids are

5 Squiffy Aspects of ADHD…that contribute to its

controversial nature:

1. No laboratory or radiological confirmatory tests or specific physical features.

2. Diagnostic criteria have changed frequently.

3. There is no curative treatment, so long-term therapies are required.

4. Stimulant drugs are thought to have abuse potential.

5. The rates of diagnosis and of treatment differ across countries.

The ADD Lobby

Parent organizationsAssociation for Children

with Learning Disabilities (ACLD)

Children and Adults with Attention Deficit Disorder (CHADD)

Drug Companies Pediatricians and

Psychiatrists

Anti-ADHD Theories Parental/societal permissiveness Decline of corporal punishment Over-achiever parents Medical capitalism Demonizing boyish behavior Neuroconfimism Dysfunctional education system Bad diet, toxins Television’s effect on the brain Hunter vs. farmer brains

Regulation of Psychoactive Drugs

DEA has 5 categories of scheduled drugs, then over the counter

ADHD stimulants are regulated the same as narcotics

Dopamine and Abuse

Antipsychotics and hallucinogens have little potential for abuse, but are still regulated

Caffeine and alcohol are not

Proposed British Reform

Decriminalization of Cannabis

Bell Curve of Brains What if the

right half of brains benefit from stimulants?

What if the right 95% does?

Dementia, Mild Cognitive Disorder The aging of society will allow increasing

medicalization of attention and memory disorders

ICD: Mild cognitive disorder - A disorder characterized by impairment of memory, learning difficulties, and reduced ability to concentrate on a task for more than brief periods. There is often a marked feeling of mental fatigue when mental tasks are attempted, and new learning is found to be subjectively difficult even when objectively successful.

Cognitive Enhancement

Therapy vs. Enhancement 5% to 35% estimates of the

use of un-prescribed stimulants by college students as study aids

Cognitive Liberty

The right to control your own brains, vs.

Society’s obligations to Protect public safety, control selling of harmful

substancesKeep people from selling themselves into

mental slavery

But what if a enhancing drug made you smarter without bad side effects?

Modafinil (Provigil)

Developed and approved as treatment for narcolepsy and “excessive day-time sleepiness”

Schedule 4 controlled substance

Review and Take Homes

3 types of ADHD according to ICD and DSM Difference between ICD and DSM Reasons for controversiality of ADHD Conrad’s complaints Alternative theories of ADHD Irrational regulation of psychoactive drugs Cognitive liberty Modafinil