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The banality of evil — Psychiatry and ADHD

Posted by Henry Bauer on 2017/04/25

“The banality of evil” is a phrase coined by Hannah Arendt when writing about the trial of Adolf Eichmann who had supervised much of the Holocaust. The phrase has been much misinterpreted and misunderstood. Arendt was pointing to the banality of Eichmann, who “had no motives at all” other than “an extraordinary diligence in looking out for his personal advancement”; he “never realized what he was doing … sheer thoughtlessness … [which] can wreak more havoc than all the evil instincts” (1). There was nothing interesting about Eichmann. Applying Wolfgang Pauli’s phrase, Eichmann was “not even wrong”: one can learn nothing from him other than that evil can result from banality, from thoughtlessness. As Edmund Burke put it, “The only thing necessary for the triumph of evil is for good men to do nothing” — and not thinking is a way of doing nothing.

That train of thought becomes quite uncomfortable with the realization that sheer thoughtlessness nowadays pervades so much of the everyday practices of science, medicine, psychiatry. Research simply — thoughtlessly — accepts contemporary theory as true, and pundits, practitioners, teachers, policy makers all accept the results of research without stopping to think about fundamental issues, about whether the pertinent contemporary theories or paradigms make sense.

Psychiatrists, for example, prescribe Ritalin and other stimulants as treatment for ADHD — Attention-Deficit/Hyperactivity Disorder — without stopping to think about whether ADHD is even “a thing” that can be defined and diagnosed unambiguously (or even at all).

The official manual, which one presumes psychiatrists and psychologists consult when assigning diagnoses, is the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, now (since 2013) in its 5th edition (DSM-5). DSM-5 has been quite widely criticized, including by such prominent psychiatrists as Allen Frances who led the task force for the previous, fourth, edition (2).

Even casual acquaintance with the contents of this supposedly authoritative DSM-5 makes it obvious that criticism is more than called for. In DSM-5, the Diagnostic Criteria for ADHD are set down in five sections, A-E.

A: “A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
     1.   Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities
           Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
a.     Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate)
b.     Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).”
and so on through c-i, for a total of nine asserted characteristics of inattention.

Paying even cursory attention to these “criteria” makes plain that they are anything but definitive. Why, for example, are six symptoms required up to age 16 when five are sufficient at 17 years and older? There is nothing clear-cut about “inconsistent with developmental level”, which depends on personal judgment about both the consistency and the level of development. Different people, even different psychiatrists no matter how trained, are likely to judge inconsistently in any given case whether the attention paid (point “a”) is “close” or not. So too with “careless”, “often”, “difficulty”; and so on.

It is if anything even worse with Criteria A(2):

“2.    Hyperactivity and Impulsivity:
Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities
       Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
a.    Often fidgets with or taps hands or feet or squirms in seat.”
and so on through b-i, for again a total of nine supposed characteristics of inattention. There is no need to cite any of those since “a” amply reveals the absurdity of designating as the symptom of a mental disorder a type of behavior that is perfectly normal for the majority of young boys. This “criterion” makes self-explanatory the reported finding that boys are three times more likely than girls to be diagnosed with ADHD, though experts make heavier weather of it by suggesting that sex hormones may be among the unknown causes of ADHD (3).

A(1) and (2) are followed by
“B. Several inattentive or hyperactivity-impulsivity symptoms were present prior to age 12 years.
C. Several inattentive or hyperactivity-impulsivity symptoms are present in two or more
settings  (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance
intoxication or withdrawal).”

It should be plain enough that this set of so-called criteria is not based on any definitive empirical data, as a simple thought experiment shows: What clinical (or any other sort of) trial could establish by observation that six symptoms are diagnostic up to age 17 whereas five can be decisive from that age on? What if the decisive symptoms were apparent for only 5 months rather than six; or five-and-three-quarters months? How remarkable, too, that “inattention” and hyperactivity and impulsivity” are both characterized by exactly nine possible symptoms.

Leaving aside the deplorable thoughtlessness of the substantive content of DSM-5, it is also saddening that something published by an authoritative medical society should reflect such carelessness or thoughtlessness in presentation. Competent copy-editing would have helped, for example by eliminating the many instances of “and/or”: “this ungraceful phrase … has no right to intrude in ordinary prose” (4) since just “or” would do nicely; if, for instance, I tell you that I’ll be happy with A or with B, obviously I’ll be perfectly happy also if I get both.
Good writing and proper syntax are not mere niceties; their absence indicates a lack of clear substantive thought in what is being written about, as Richard Mitchell ( “The Underground Grammarian”), liked to illustrate by quoting Ben Jonson: “Neither can his Mind be thought to be in Tune, whose words do jarre; nor his reason in frame, whose sentence is preposterous”.

At any rate, ADHD is obviously an invented condition that has no clearly measurable characteristics. Assigning that diagnosis to any given individual is an entirely subjective, personal judgment. That this has been done for some large number of individuals strikes me as an illustration of the banality of evil. Countless parents have been told that their children have a mental illness when they are behaving just as children naturally do. Countless children have been fed mind-altering drugs as a consequence of such a diagnosis. Some number have been sent to special schools like Eagle Hill, where annual tuition and fees can add up to $80,000 or more.

Websites claim to give information that is patently unfounded or wrong, for example:

“Researchers still don’t know the exact cause, but they do know that genes, differences in brain development and some outside factors like prenatal exposure to smoking might play a role. … Researchers looking into the role of genetics in ADHD say it can run in families. If your biological child has ADHD, there’s a one in four chance you have ADHD too, whether it’s been diagnosed or not. … Some external factors affecting brain development have also been linked to ADHD. Prenatal exposure to smoke may increase your child’s risk of developing ADHD. Exposure to high levels of lead as a toddler and preschooler is another possible contributor. … . It’s a brain-based biological condition”.

Those who establish such websites simply follow thoughtlessly, banally, what the professional literature says; and some number of academics strive assiduously to ensure the persistence of this misguided parent-scaring and children-harming. For example, by claiming that certain portions of the brains of ADHD individuals are characteristically smaller:

“Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis” by Martine Hoogman et al., published in Lancet Psychiatry (2017, vol. 4, pp. 310–19). The “et al.” stands for 81 co-authors, 11 of whom declared conflicts of interest with pharmaceutical companies. The conclusions are stated dogmatically: “The data from our highly powered analysis confirm that patients with ADHD do have altered brains and therefore that ADHD is a disorder of the brain. This message is clear for clinicians to convey to parents and patients, which can help to reduce the stigma that ADHD is just a label for difficult children and caused by incompetent parenting. We hope this work will contribute to a better understanding of ADHD in the general public”.

An extensive detailed critique of this article has been submitted to the journal as a basis for retracting that article: “Lancet Psychiatry Needs to Retract the ADHD-Enigma Study” by Michael Corrigan & Robert Whitaker. The critique points to a large number of failings in methodology, including that the data were accumulated from a variety of other studies with no evidence that diagnoses of ADHD were consistent or that controls were properly chosen or available — which ought in itself be sufficient reason not to find publication.

Perhaps worst of all: Nowhere in the article is IQ mentioned; yet the Supplementary Material contains a table revealing that the “ADHD” subjects had on average higher IQ scores than the “normal” controls. “Now the usual assumption is that ADHD children, suffering from a ‘brain disorder,’ are less able to concentrate and focus in school, and thus are cognitively impaired in some way. …. But if the mean IQ score of the ADHD cohort is higher than the mean score for the controls, doesn’t this basic assumption need to be reassessed? If the participants with ADHD have smaller brains that are riddled with ‘altered structures,’ then how come they are just as smart as, or even smarter than, the participants in the control group?”

[The Hoogman et al. article in many places refers to “(appendix)” for details, but the article — which costs $31.50 — does not include an appendix; one must get it separately from the author or the journal.]

As usual, the popular media simply parroted the study’s claims, illustrated by headlines cited in the critique:

And so the thoughtless acceptance by the media of anything published in an established, peer-reviewed journal contributes to making this particular evil a banality. The public, including parents of children, are further confirmed in the misguided, unproven, notion that something is wrong with the brains of children who have been designated with a diagnosis that is no more than a highly subjective opinion.

The deficiencies of this article also illustrate why those of us who have published in peer-reviewed journals know how absurd it is to regard “peer review” as any sort of guarantee of quality, or even of minimal standards of competence and honesty. As Richard Horton, himself editor of The Lancet, has noted, “Peer review . . . is simply a way to collect opinions from experts in the field. Peer review tells us about the acceptability, not the credibility, of a new finding” (5).

The critique of the Hoogman article is just one of the valuable pieces at the Mad in America website. I also recommend highly Robert Whitaker’s books, Anatomy of an Epidemic and Mad in America.


(1)  Hannah Arendt, Eichmann in Jerusalem — A Report on the Banality of Evil. Viking Press,
1964 (rev. & enlarged ed.). Quotes are at p. 134 of PDF available at
https://platypus1917.org/wp-content/uploads/2014/01/arendt_eichmanninjerusalem.pdf
(2)  Henry H. Bauer, “The Troubles With Psychiatry — essay review of Saving Normal by Allen
Frances and The Book Of Woe by Gary Greenberg”, Journal of Scientific Exploration,
29  (2015) 124-30
(3)   Donald W. Pfaff, Man and Woman: An Inside Story, Oxford University Press, 2010: p. 147
(4)   Modern American Usage (edited & completed by Jacques Barzun et al. from the work of
Wilson Follett), Hill & Wang 1966
(5)    Health Wars: On the Global Front Lines of Modern Medicine, New York Review Books,
2003, p. 306

 

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