It is a mantra of
medical and social science reports that when cases of a new disorder are found,
they are described as being “only the tip of the iceberg”. Autism, alcoholism, child sexual abuse, drug
abuse, diabetes, dyslexia, high cholesterol, high blood pressure, hyperactivity,
and post-traumatic stress disorder are examples of conditions which are
frequently described in this way. There may be several hundred others. According
to the iceberg analogy there is a lot of illness and misery out there. This
search for the afflicted (the iceberg beneath water level) may be motivated by
altruistic concern for others or it might be a cynical ploy to drum up business
for drug companies and purveyors of therapy.
Some under-counting is understandable.
Many conditions are not nice to admit to, and are best denied. Some are
illegal. Few people willingly admit to a stain on their character, a permanent
flaw in their fundamental nature. Further, many citizens have been living their
lives under the misapprehension that they were normal, and do not take kindly
to being labelled in any way. They do not wish to be accused of having spoken
prose all their lives.
Some over-counting is understandable. If the new diagnosis is about
a transitory and treatable difficulty due to outside causes, it can become
fashionable, with celebrity sufferers recruiting fellow victims and forming
lobbying groups. As Lady Bracknell observed in The Importance of being Ernest: “None of us are perfect. I myself am peculiarly
susceptible to draughts”. Confessing to a minor
diagnosis can be cool. To say “I am
illiterate” is not a career boosting move. The attribution is inner and
permanent. To ask “How good are your
facilities for registered dyslexics?” has a much better ring to it. The
narrative has moved from a personal failing to a social requirement to provide
for a specific and legitimate handicap.
How can we obtain
accurate numbers?
We cannot find out
until we ask the question. There are so many questions to be asked in
psychology and medicine that a selection must be made, and some will be left
out. This makes sense because some conditions are much commoner than others.
Special interest groups argue for the inclusion of particular lines of enquiry
and this usually leads to a higher rate of reported of cases, which confirms
the “tip of the iceberg” theory. If a
doctor or psychologist has been on a training course, they will begin to
diagnose more of those sorts of cases, sometimes correctly, often incorrectly. So,
we cannot find until we look, yet once we are on the lookout we may see cases
where none exist.
Autism is a good
example. This severe condition exists. Accurate diagnosis depends on
training and experience, and there are well-established indicators and measures
of severity. Unfortunately, what was once a narrow diagnostic category has
entered popular culture as meaning anyone who is not particularly social and is
a little too interested in technical matters. For those who fail to get the autism diagnosis,
Asperger’s syndrome may be seen as a consolation prize. By the way, these
syndromes are not laughing matters, but the search for diagnostic labels is a
two-edged sword. The sufferer may get
the reassuring legitimacy provided by a diagnostic authority and gain resources
from government agencies, but might possibly be blocked from being treated normally
and thus exacerbate and prolong their difficulties.
There are powerful forces moving us toward the proliferation of diagnosed disorders.
One of the few growth stories in our moribund economy is provided by The
Diagnostic and Statistical Manual of Mental Disorders. When launched in 1968 it
contained 182 disorders. By 1980 it had reached 265, by 1994 there were 297 and
the next revision out soon will very probably raise that number. To the cynical eye, DSM is a child of the US health
insurance industry: no patient can be repaid their medical bills unless the
doctor writes down a diagnostic number. No number, no cash. So, the all difficulties
of life must be numbered, and the greater the number of diagnoses the greater
the opportunities for therapists of all types. The iceberg tendency is in the ascendant.
Layers of an onion
If you peel away all the layers of the onion, it ceases to
exist. None of the layers are the onion itself, yet no onion is left without
them. So it is with the endless reclassifications of normal reactions as
disorders. The person is slowly reduced
by a set of dissociative classifications. They become “person-with”: person with
diabetes, person-with memory problems, person-with anger management issues. Given a large enough armamentarium of
diagnoses, normality ceases to exist.
One can do some rough calculations based on the prevalence
of diagnosed disorders. The World Health
Organization reported in 2001
that one in four people meet criteria for some form of mental disorder or brain
condition at some point in their life. Believe that if you will, though of
course life time estimates could include one short episode in an otherwise
untroubled life. Here are the ranges
given for the prevalence of each condition in 14 countries: anxiety 2.4 to
18.2%, mood disorders 0.8 to 9.6%, substance abuse 0.1 to 6.4%, impulse-control
disorders 0 to 6.8. The authors are of the iceberg tendency, and believe that
their figures are under-estimates. Clearly, some countries have not come into
line with the putative Central Classification System, and don’t realise quite
how miserable and disordered people are.
If we repeat the procedure for physical health, we would have
to discount those who were too fat, too thin, all those with chronic
conditions, and perhaps those who are being medicated because they may be
thought to be at risk. For example, giving statins those who are healthy but
have high cholesterol (of the bad sort), which is at best an indicator, and not
a disease itself. It would be easy to show that at least 25% of the population
were unhealthy at some time in their lives and probably chronically unhealthy
for the last third of their lives.
Putting together the mentally disordered and the physically
unwell results in a small core of citizens being classified as “well”, and even
then, perhaps a more detailed enquiry could turn up hidden problems. Peeling away
the onion transforms normality into layers of syndromes for which invoices can
be issued. The classificatory project has colonial ambitions, and a whole
industry behind it.
Can order be brought
to this chaos?
Contemporary psychiatry and psychology believe they have the
antidote to hand. They restrict diagnostic categories to a set of well-defined
indicators which have to achieve set levels of severity and duration. In sober
hands, such defined disorders can be diagnosed in a responsible fashion.
Questionnaires can be
a help. Patients are more likely to admit to drinking too much and to having
served time in prison when confessing to a piece of paper rather than a
psychiatrist. It is a commonplace of clinical psychology interviews that if one
wants to ask about drug abuse it is easier to hand the patient a list of drugs
and ask casually “which of these have you used”? The list begins with
pain-killers and antibiotics, and goes on to harder stuff. A bit of distance
aids confession.
However, humans are
tricky. They deny bad characteristics, complain loudly about aches and
pains when sympathy or compensation are offered, and contradict themselves when
the mood takes them. They look up diagnoses on the internet, and learn the
answers to interview questions.
Why not treat them
like fish in the sea, and net and tag them? Put a net into the sea, pull
out the fish and tag each one with a shiny Time 1 tag. Then, a few weeks later,
visit the same area and repeat the process, tagging each fish with a Time 2
tag. While doing this you will catch a few fish with a Time 1 tag already on
them. Note the number of such fish. It you really want to be accurate, repeat
the process a third time.
Charming as it might be for psychologists to become fishers
of men, members of the public are likely to object to being tagged in the name
of science. We cannot use nets or tranquiliser darts. However, a name is a tag.
Most places we go, we leave a name. Checking names does the trick. For example,
how many drug users are there in North London? The Police have one estimate,
based on a list of arrests. The Courts have another list of names. The General
Practitioners have their own lists of registered addicts. Each of those lists
is a net, which tags every person.
Capture-recapture
methodologies come to the rescue here. The Lincoln-Petersen method, in the interests
of simplicity shown here for only two nettings is:
N= (M C) / R
Where:
N = Estimate of total population size
M = Total number of animals captured and marked on the first visit
C = Total number of animals captured on the second visit
R = Number of animals captured on the first visit that were then
recaptured on the second visit
So, let us estimate the number of
hard drug users in a defined neighbourhood.
The Police have a list of names of people they have arrested, and 10 of
those live in the neighbourhood. The local drug clinic has a list of names of
users and 15 of those live in the neighbourhood. Five of those 15 are also on
the Police list, so they have been “re-captured”.
In this example, the Lincoln–Petersen
method estimates that there are 30 drug users in the neighbourhood.
Perhaps we have to turn away from self-proclaimed claims of disorder and get
out our nets. Using our nametags instead of nets and physical tags, we have to
check for the overlap of names in different lists, and then do our
calculations. Sure, we can give citizens questionnaires about their sexual
behaviour, but it might be better to check names on Sexually Transmitted
Disease Clinics to get more reliable estimates, and to calibrate the
questionnaire replies. Given access to the data, by tracing every purchase and
every location visited, every bill paid or ignored, every credit card
transaction and every health clinic attendance, every TV program watched we will
finally find out, with considerable reliability, who we are, and what mental state
we are in.
So, when the next new mental disorder is described in the
media, always ask yourself: is this the
tip of the iceberg or the skin of an onion?
No comments:
Post a Comment