The trend to consider certain conditions and psychological states “diseases” or “illnesses” (which implies biological causality) is bad because:
This is why I thought that tabooing “associated words” would be a good thing. Many treatable conditions in medicine are not considered “diseases” or “illnesses” anymore, and they shouldn’t be. This especially applies to psychiatry. Many diagnoses cannot be made unless the condition “causes significant harm to the patient” is met.
I would go even further than most doctors, and say that it’s a failure of medicine to only try to normalize harmful conditions instead of trying to improve upon what’s considered normal. This means that the language of medicine has to change even further. A diagnosis certainly shouldn’t automatically be a “disease” and not even a “disorder”.
It narrows the range of what’s considered acceptable human variation. Consider e.g. a grumpy guy. Would it be good if he were to be diagnosed with the illness of grumpiness (with associated social costs) and prescribed a pill for that?
“Acceptable human variation” and “illness of grumpiness” is a again a way to say there should be stigma attached to a diagnosis. I don’t think there should and this is a separate problem from whether certain conditions should be considered treatable. If the guy thinks his grumpiness is a problem and causes significant harm, and it can be treated without side effects that are unacceptable to him, and he would knowingly accept the social costs, then I think he should have the option of treatment available. A diagnosis isn’t an illness, it’s a label that doctors use to communicate with each other.
Also keep in mind that therapy is a medical intervention too, and is usually better for specific behavioral problems.
It assumes biological causality for what are not necessarily problems of human biology (or biochemistry).
Like TheOtherDave said, the pill is unlikely to work, unless there is a biological mechanism involved.
There are considerable forces in the business world which would stand to gain huge amounts of money were this to happen. This is not an outright argument against per se, but it does make one suspicious.
In this case one should be suspicious of all treatments and not just psychiatric ones, and perhaps one should. I think this is a separate problem from whether certain conditions should be considered treatable. There’s certainly a need for a system that has less perverse incentives.
Well, I think you and I are approaching this thing from opposite directions. You’re an optimist and I’m a cynic. Here’s what I think you are imagining:
Grumpy Guy: Doctor, I’m grumpy. I don’t want to be grumpy, it seriously screws up my life. Can anything be done to make me less grumpy?
Doctor: Hmm… Well, there that pill. Try it, see if it helps you.
And here’s what I’m imagining:
Grumpy Guy: I’m here for my annual check-up.
Doctor: Hmm, you look grumpy. That’s not good. Tell me, does grumpiness lead to impairment of your social life?
Grumpy Guy: Um, I don’t know. I guess..
Doctor: Aha! I hereby diagnose you with grumpiness. Here are two pills, come visit me in a month, we’ll adjust the dosage and the interaction of the two pills. You will have to take them for the rest of your life. See you in a month!
I suppose my situation demands optimism. However, I think both scenarios you’re describing do happen, and I have no idea in what proportions. There’s also a whole spectrum of behaviour between them.
I don’t know how to prevent the scenario you’re seeing, some patients are really passive. Any ideas?
Some of my optimism must stem from the fact that I’m finnish. Mostly public health care, minimal advertising and bans on most kinds of bribery help. Unfortunately the situation is quickly eroding due to privatization. (I’m not against privatization per se, just the way it’s usually done.)
The passivity of a patient is not a good reason for the doctor to decide that he now has to run the patient’s life.
must stem from the fact that I’m finnish. Mostly public health care, minimal advertising and bans on most kinds of bribery help.
More things help like cultural and religious uniformity (yes, I know about the Swedish minority, no, they’re not different enough to matter) which leads to the high level of trust in the society, specifics of culture (protestant work ethic, strong cultural disapproval of cheating), etc.
The passivity of a patient is not a good reason for the doctor to decide that he now has to run the patient’s life.
In the best of all possible worlds I agree. What if the patient has a physical condition that lowers his quality of life or shortens it? How does a passive patient get help? Should all persuasion be banned? What’s your solution to the situation?
More things help like cultural and religious uniformity (yes, I know about the Swedish minority, no, they’re not different enough to matter) which leads to the high level of trust in the society, specifics of culture (protestant work ethic, strong cultural disapproval of cheating), etc
In theory, you offer help (which is different from force it) which the patient might accept or reject.
There are more or less persuasive ways to offer help. In many situations, I would try to be very persuasive. That’s not forcing it is it? I don’t think there’s any danger that treatment of grumpiness would be forced in the strictest meaning of the word.
Well, as I said, it depends. Someone with a clinical depression requires a different approach from someone who, say, doesn’t want to take statins even though he has high LDL.
The real underlying issue is that of power. Doctors that I know tend to have the unfortunate tendency to develop a God complex—they get used to simple, uninformed people coming to them asking for help and the doctors literally having life-and-death power over these people. But that’s a different discussion.
Patient intelligence and education is a huge factor. Many people don’t understand probabilities at all and can’t differentiate between real evidence and rhetorical tricks.
I have conflicting feelings about how I should handle patients I can’t adequately inform because of their limitations. What’s the point of trying to explain real evidence if delivery is all that matters in their decision process? It’s not like there’s any real exchange of information in those situations.
Yes, I understand the problem. I don’t know if there’s a good solution. Saying “it depends” is a cop-out, but on the other hand there is no global optimum and all you have is different trade-offs. And picking among different trade-offs—well, it depends and we’re back to square one.
To whomever downvoted every comment by Lumifer: I had to break my policy and upvote him for no good reason. I don’t believe in punishing conversation I want to be part of, especially if it’s about a topic where bias is to be expected. I also think that reasons for systematic downvoting should be stated if one expects it to have any positive effect.
Thanks but I don’t really care that much about karma. I have enough so that the website doesn’t limit what I can do and otherwise it’s a number. Occasionally someone will just go through a bunch of my posts and click-click-click-click on all of them. Oh well, maybe he just likes to click on things… :-)
This is why I thought that tabooing “associated words” would be a good thing. Many treatable conditions in medicine are not considered “diseases” or “illnesses” anymore, and they shouldn’t be. This especially applies to psychiatry. Many diagnoses cannot be made unless the condition “causes significant harm to the patient” is met.
I would go even further than most doctors, and say that it’s a failure of medicine to only try to normalize harmful conditions instead of trying to improve upon what’s considered normal. This means that the language of medicine has to change even further. A diagnosis certainly shouldn’t automatically be a “disease” and not even a “disorder”.
“Acceptable human variation” and “illness of grumpiness” is a again a way to say there should be stigma attached to a diagnosis. I don’t think there should and this is a separate problem from whether certain conditions should be considered treatable. If the guy thinks his grumpiness is a problem and causes significant harm, and it can be treated without side effects that are unacceptable to him, and he would knowingly accept the social costs, then I think he should have the option of treatment available. A diagnosis isn’t an illness, it’s a label that doctors use to communicate with each other.
Also keep in mind that therapy is a medical intervention too, and is usually better for specific behavioral problems.
Like TheOtherDave said, the pill is unlikely to work, unless there is a biological mechanism involved.
In this case one should be suspicious of all treatments and not just psychiatric ones, and perhaps one should. I think this is a separate problem from whether certain conditions should be considered treatable. There’s certainly a need for a system that has less perverse incentives.
Well, I think you and I are approaching this thing from opposite directions. You’re an optimist and I’m a cynic. Here’s what I think you are imagining:
Grumpy Guy: Doctor, I’m grumpy. I don’t want to be grumpy, it seriously screws up my life. Can anything be done to make me less grumpy?
Doctor: Hmm… Well, there that pill. Try it, see if it helps you.
And here’s what I’m imagining:
Grumpy Guy: I’m here for my annual check-up.
Doctor: Hmm, you look grumpy. That’s not good. Tell me, does grumpiness lead to impairment of your social life?
Grumpy Guy: Um, I don’t know. I guess..
Doctor: Aha! I hereby diagnose you with grumpiness. Here are two pills, come visit me in a month, we’ll adjust the dosage and the interaction of the two pills. You will have to take them for the rest of your life. See you in a month!
I suppose my situation demands optimism. However, I think both scenarios you’re describing do happen, and I have no idea in what proportions. There’s also a whole spectrum of behaviour between them.
I don’t know how to prevent the scenario you’re seeing, some patients are really passive. Any ideas?
Some of my optimism must stem from the fact that I’m finnish. Mostly public health care, minimal advertising and bans on most kinds of bribery help. Unfortunately the situation is quickly eroding due to privatization. (I’m not against privatization per se, just the way it’s usually done.)
The passivity of a patient is not a good reason for the doctor to decide that he now has to run the patient’s life.
More things help like cultural and religious uniformity (yes, I know about the Swedish minority, no, they’re not different enough to matter) which leads to the high level of trust in the society, specifics of culture (protestant work ethic, strong cultural disapproval of cheating), etc.
In the best of all possible worlds I agree. What if the patient has a physical condition that lowers his quality of life or shortens it? How does a passive patient get help? Should all persuasion be banned? What’s your solution to the situation?
All good points. Are you finnish? :)
By the way, I’m not downvoting you.
In theory, you offer help (which is different from force it) which the patient might accept or reject.
In practice, it depends, as usual.
No, but I have some familiarity with the Baltic Sea region.
There are more or less persuasive ways to offer help. In many situations, I would try to be very persuasive. That’s not forcing it is it? I don’t think there’s any danger that treatment of grumpiness would be forced in the strictest meaning of the word.
Well, as I said, it depends. Someone with a clinical depression requires a different approach from someone who, say, doesn’t want to take statins even though he has high LDL.
The real underlying issue is that of power. Doctors that I know tend to have the unfortunate tendency to develop a God complex—they get used to simple, uninformed people coming to them asking for help and the doctors literally having life-and-death power over these people. But that’s a different discussion.
Patient intelligence and education is a huge factor. Many people don’t understand probabilities at all and can’t differentiate between real evidence and rhetorical tricks.
I have conflicting feelings about how I should handle patients I can’t adequately inform because of their limitations. What’s the point of trying to explain real evidence if delivery is all that matters in their decision process? It’s not like there’s any real exchange of information in those situations.
Yes, I understand the problem. I don’t know if there’s a good solution. Saying “it depends” is a cop-out, but on the other hand there is no global optimum and all you have is different trade-offs. And picking among different trade-offs—well, it depends and we’re back to square one.
To whomever downvoted every comment by Lumifer: I had to break my policy and upvote him for no good reason. I don’t believe in punishing conversation I want to be part of, especially if it’s about a topic where bias is to be expected. I also think that reasons for systematic downvoting should be stated if one expects it to have any positive effect.
Thanks but I don’t really care that much about karma. I have enough so that the website doesn’t limit what I can do and otherwise it’s a number. Occasionally someone will just go through a bunch of my posts and click-click-click-click on all of them. Oh well, maybe he just likes to click on things… :-)