What Counts as a Disorder?

One of the most interesting terms that gets thrown around a lot these days is “disorder.” A lot of this is driven by people’s growing attention to mental health, which wasn’t taken seriously for most of our history. Ever since ancient Greece, Western cultures bought into the idea that “mind” and “body” were separate things, but that’s not true. Whatever the “mind” is (a deceptively tricky question), it has a lot to do with the brain, and the brain is part of the body.

If the brain is part of the body, surely that means it’s as susceptible to biological dysfunction as the rest of the body. Things that go physically wrong with the brain can cause problems for the functioning of the mind, so if we take physical problems seriously, we should take mental problems seriously, too, because what’s mental is intimately related to what’s physical. That we’re finally admitting this is a welcome development.

Freud Comic

Of course, getting rid of the mind-body dichotomy wasn’t always smooth sailing for psychologists.

Still, it’s been a contentious one. Some disorders, like PTSD (Post Traumatic Stress Disorder), are pretty widely acknowledged, but some are still the subject of heated disagreements. The one that immediately comes to mind is ADD (Attention Deficit Disorder) or its near-cousin ADHD (Attention Deficit Hyperactivity Disorder). Some people argue ADD and ADHD are not real disorders; they’re a psychological fad born out of some compulsion to diagnose everything as a “disorder” or, more cynically, to sell pills and extra therapy sessions.

The usual response of psychologists and their defenders is to cite the experimental psychological literature. It’s scientifically proven, so the argument goes, that some people have shorter attention spans than others. What’s more, it has to do with their biology. It’s a physical fact. That means it’s rubbish to say ADD and ADHD aren’t “real.” They’re as “real” as AIDS or cancer.

What I want to argue in this post is that both sides are right and both sides are wrong. This is chiefly because there are not one but two issues at stake in the question, “Is ADD a real disorder?” There’s the question “Is ADD a real disorder?” and there’s the question, “Is ADD a real disorder?” Psychologists can give us a reliable answer to the first question, but not the second. Or at least, so I’ll argue.

ADD is a Real Disorder

There can be very little question whether ADD is real. People don’t even need to read academic articles to know that. All they have to do is cast their memory back to 1st grade. Everyone who ever attended public school either had a few classmates who couldn’t sit still no matter how many ingenious threats their loosely law-bound teacher wielded at them or, if they didn’t, they were that student.

Calvin Hobbes

Nor is it a grand leap to suppose that this has something to do with those students’ biology. Maybe some kids don’t sit still because they’re obstinate or don’t really care to try, but anyone with kids, nephews or nieces can notice how much their energy and attention levels vary even from a very young age. Surely one of the things that causes such variation is simple biological variation – their hormone levels, their DNA, whatever.

As it happens, psychological research heavily confirms the suspicions of those of us with, erm, energetic nieces and nephews. There’s a lot of evidence, even beyond our memories of Blake running rampant through Ms. Rousch’s classroom, that ADD is real. That is, there’s lots of evidence that people vary in their attention levels from birth, and that most of this is due to heredity. When people argue that ADD “isn’t real” or was “made up” by psychologists, they’re just plain wrong.

But that’s not the whole story.

How do we Know Whether ADD is a Real Disorder?

It isn’t the whole story because there’s still the question of what counts as a disorder. There seems to be a general confusion about who gets to decide questions like this. For example, the website for CHADD, which stands for “Children and Adults with Attention Deficit Disorder,” includes a sub-heading that gamely claims “Real Science Defines ADHD as Real Disorder.” This seems to imply that scientists are the right authorities for deciding which psychological and behavioral conditions ought to be classified as “disorders.” Real scientists are the ones who decide what a real disorder is.

Lots of other people think this way, too. It’s not uncommon to be a fly on the wall of some Internet conversation that goes like this:

Skeptic: “ADD isn’t a real disorder.”

Well-Read Person: “Yeah it is. Look at the DSM-5!”

(The DSM-5 is the “Diagnostic and Statistical Manual of Mental Disorders.” It’s like a handbook of psychological disorders issued by the professional psychological community.)

The Well-Read Person in this conversation has a point that ADD is real, in that it describes an actual, well-documented biological difference between some people and others. But they, like CHADD, are wrong if they think the professional psychological community – or any professional community – is the right authority to consult about the question of what a “disorder” is.

Smokey-Expert-Cartoon-300x300That seems like a weird thing to say, but that’s just because we as a society are frequently not very clear on the kind of authority “expert” status grants to those who possess it. We often think experts are authorities on more things than what is actually implied by their expertise. Let me explain.

Of all expert communities, scientific communities are the ones that most deserve our respect. Whereas we would be hesitant to say that being a professional ethicist means the rest of us should just accept their ideas about right and wrong, most people would agree that being a professional physicist means the rest of us should take a back seat when it comes to designing rockets.

But there are some questions that involve physics where it would still be wrong for us to defer to physicists. For example, we ought to defer to the expertise of physicists when it comes to deducing what the likely atmospheric effects of testing an atomic bomb would be. But we shouldn’t defer to them when it comes to deciding whether we ought to conduct such a test. That’s because deciding whether to test an atomic bomb is an ethical question. It involves not only knowledge of what physically happens when people test atomic bombs, but also requires us to weigh our values. If the effects on the atmosphere would be negligible, would conducting a test be worth the extra knowledge and political security granted by possession of an atomic bomb? Is any effect too much, considering the devastating power of atomic bombs in general?

Questions like these involve physics. That means we certainly ought to consult the knowledge of the physics community in order to more clearly understand what testing an atomic bomb entails. But that does not mean physicists should be treated as “authorities” who ought to decide whether or not we as a society ought to test atomic bombs. That question involves more than just atoms and motion. It involves our values, how we weigh the ultimate costs and benefits of conducting tests like these. For questions like these, there are no clear-cut “experts.”

The same thing is true when we categorize something as a “disorder.” A disorder means something is wrong, that it’s a deviation from what we view to be the correct standards for a healthy human life. Who decides what those standards ought to be?

Willy Wonka Socrates

Socrates being Socrates

Many people might still think it should be psychologists. “Who better to decide what constitutes a healthy mind than the people who study it for a living?” they might object. And at first, this sounds reasonable. After all, how controversial could the term “healthy” be? To say that a thing as clear-cut as health involves value judgments, or is subjective, seems like the worst kind of postmodernism, the kind that treats the question, “Do rocks exist?” as laden with a level of uncertainty equivalent to the question Socrates posed to the unfortunate Euthyphro: “Is what’s good good because the gods love it, or do the gods love it because it’s already good?”

But no matter how you slice it (and no matter how much you hate postmodernism), the question of health is heavily subjective. What counts as “healthy” depends on what we value, what we want out of life. Being obese is unhealthy because people value mobility and don’t want to die of a heart condition at 36. Being addicted to heroin is unhealthy because people want to be in control of their own lives, not under the command of a chemical that compels them to use it no matter what the consequences to their friends, family and other relationships.

What counts as healthy is also situational. Cutting off your arm off isn’t generally a move toward greater health. But if your arm is pinned under a fallen tree and the only way to get out is to cut it off, cutting off your arm can be the most healthy thing you could do.

If the fact that deciding what’s healthy is a value judgment is clear when it comes to physical health, all the more so when it comes to mental. No better evidence exists than the DSM’s own history, which classified homosexuality as a disorder for over 20 years. Why? Was it because scientific “evidence” drove them to that conclusion? Certainly not. It was because of the values held by the overwhelming majority of Americans at that time. According to those judgments, homosexuality was a deviation from the natural order. People were “supposed” to be straight. To be straight was to be well ordered. By definition, then, to be homosexual was to be disordered.

Being gay didn’t get put in the DSM as a “disorder” because psychological experts figured out it was a problem with the human mind. It got in there because psychologists already had an idea of what it meant to be a “healthy” mind (one that many of them didn’t bother very much to question). Where did that idea come from?

Nowhere but society itself. Psychology gets its idea of what it means to be “well ordered” or “healthy” from society, not the other way round.

It’s always this way, and neither can nor should be any other. To decide what counts as a disorder, we first have to have a definition of what counts as well ordered, and that decision requires more than being an expert in psychology. Specifically, it requires us to decide what the good life is. To decide whether someone’s an alcoholic, we have to decide what a “healthy” tradeoff is between a bit of jovialty with friends today and the repercussions to our brain and kidneys tomorrow. To decide whether someone’s bipolar, we have to decide what counts as a life too absent of emotion — which some call “stoicism,” others call “callousness” and still others call “sociopathy” — and the life excessively ruled by emotion — which some call “passionate” others call “unreasonable” and still others call “unstable.”

Hitchens Alcohol

Christopher Hitchens smoked and drank heavily, which likely led to his death of esophageal cancer in his 60s, yet he maintained until his death that the trade was worth it. Was his a “healthy” life? Who ought to decide?

I suspect that when a lot of people argue that ADD isn’t a real disorder, what they really mean is that ADD isn’t a real disorder. They don’t mean there’s no such thing as a kid who can’t sit still in class. What they mean is that there’s nothing wrong with being a kid who can’t sit still in class. What they mean is that when psychologists tell us that 5-10% of children are diagnosed with “Attention Deficit Hyperactivity Disorder,” that tells us more about the skewed values of our society and the problems with our expectations of small children than it does about how “disordered” our children really are.

Well Ordered for What?

The other issue with too readily calling ADD and ADHD “disorders” is that doing so often causes us to overlook the ways these conditions can actually be beneficial. Kids with ADHD are often a terror for elementary school teachers because of their inability to sit still and keep quiet in a class they were forced to attend. But the same children are often able to pour themselves into the activities they love with an energy that is unmatched by children without ADHD, and this ability stays with them through adulthood. Many scientists, writers, artists, academics and inventors have ADHD, and it actually helps them focus for long hours on tasks that capture their imaginations. The same condition that makes elementary school students hard to handle as children often makes them excellent scientists, artists and inventors as adults.

Besides this, ADHD can be beneficial even for people who won’t become scientists or inventors. ADHD helps people rapidly flit their attention from one thing to another. This is a useful skill for parents and teachers. And, as Scott Barry Kaufman has pointed out, we even value some of the characteristics of ADHD for themselves, regardless of what benefits they can have for adults. Those of us who fondly remember the comic strip Calvin and Hobbes, and cherish the kids who remind us of them, ought to take pause at the idea that the lovable impulsivity, creativity and imagination displayed by Calvin constitute a “disorder.”

calvinADHD

Taken from Cerulean Sanctum (not thought to be a Bill Watterson original), this comic makes the point rather poignantly.

When we call something “ordered,” it always implies a “for what?” A microwave is well ordered for heating up leftover General Tso’s, but is utter rubbish for commuting to work. My hybrid laptop/tablet is amazing for grad school, but a hopeless piece of junk when it comes to playing virtual reality games. To call something “disordered” in general is senseless. We have to know what something’s for in order to decide whether or not it’s disordered.

The purpose of a sound mind is to live a good life. When we call a psychological condition a “disorder,” we’re implying that condition hampers our ability to live a good life. To call ADHD simply a “disorder” is to imply that it detracts from the good life significantly more than it adds to it.

Is this the case? I think the discussion above about creativity, functionality, and Calvin & Hobbes should give us pause, at the very least.

Who Decides what Counts as a Disorder?

I think ADD and ADHD are real, but I also don’t think they ought to count as disorders. In the same way, being good at relationships but not math is a real situation lots of us find ourselves in, but that doesn’t make being good at relationships but not math a disorder. Instead, these are simply alternative arrangements of the mixed bag of talents and blind spots each of us carries into every phase of our life. We ought to acknowledge our strengths and deficiencies, working on them to when we can and working with them when we can’t, but we ought also to resist the too-common temptation to look at only one aspect of a human life and jump to the conclusion that it’s a “disorder,” without ever following up with an explanation of “for what.”

Am I right about whether ADHD ought to count as a disorder? I don’t know. I may well be wrong. But I don’t think my rightness or wrongness can be rightfully decided by the DSM-5, or the community of professional psychologists, or any other “accredited” body. The decision about what counts as a disorder depends on what we think the good life is, and that’s a question for which there are no experts.

Psychologists can tell us which conditions are real, in the sense that they’re caused by biology, trauma, or any other physiological route, and that’s vitally important. But their authority does not extend to what we ought to consider to be a healthy, well-ordered life. We ought to resist the idea that anyone has any special kind of authority in deciding the right answer to that question.

Instead, we ought to discuss the question in the public forum and listen to those who have the disorder as well as those who live and work with them. Once this is done, we’ll be in the best place we can be to judge whether a given condition ought to be considered a “disorder” or whether it’s just an arrangement of talents and blind spots that’s different from our own. In doing so, we might just find ourselves treasuring the many unique arrangements of talents and blind spots called the human “personality,” rather than treating those that do not fit into one particular, largely unquestioned prototype.

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