The articles in this special issue take the practices associated with the DSM as objects of scrutiny. In doing so, they throw the DSM’s limitations into sharp relief. Its knowledge base does not hold up well to scientific scrutiny. In many instances, it does not promote good care. Its evidentiary base is shoddy. For researchers, teachers, or clinical practitioners, critical distance from the DSM is intellectually responsible and ethically necessary. Following David Harper’s urging, we can inculcate a critical consciousness in our students and trainees regarding this and other tools of the ‘psy’ trade. When we teach about psychodiagnosis, we can also teach about the historicity of categories of psychological disorder and of psychological knowledge more generally. We can also discuss with clinical trainees how the workaday language practices of mental health professionals (such as those Goicoechea describes) tacitly reaffirm the subordination of patients and uphold institutional power (Rossiter, et al., 1998). (7)

Included in the issue are two full length essays, several shorter “Points of View” essays, and three research articles. The abstracts (or links to the full document) have been posted below.

Essays

Diagnosis and its discontents: Critical perspectives on psychiatric nosology and the DSM

Suzanne R Kirschner

Recent writings that critically analyze psychiatric diagnostic categories and the practices that are intertwined with them have descriptive, contextualizing and moral dimensions. Descriptive projects depict major trends in psychiatric classification. They focus on three such trends: medicalization, an increase in both the number of diagnostic categories and the number of persons to whom they are ascribed, and a move towards framing both pathological and normative behaviors and experiences in neurobiological terms. Contextualizing projects explore how micro- and macrosocial, cultural and political economic elements influence both how diagnostic categories take form and how people who live under the description of those categories interact with them. Many descriptive and contextualizing projects also have a moral dimension: they are motivated by questions about what constitutes help for mentally distressed or impaired persons as well as by concerns that some diagnostic labels and practices may cause harm. Such critical consciousness seems to have grown in tandem with increased medicalization and biological reductionism in psychiatry, and should be further promoted in the future.

Whose account matters? A challenge to feminist psychologists

Gail A Hornstein

Most critiques and commentaries concerning the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) focus on the expanding scope of the system, on particular categories of disorder, or on unwarranted claims about the biological bases of symptoms embedded in DSM descriptions. In contrast, this essay focuses on phenomenology, the subjective experiences of those supposedly being categorized by this whole framework. In addition to allowing us to see extreme states and unusual perceptions, thoughts, actions, and feelings with fresh eyes – from the perspective of the distressed person’s own categories and explanations – a phenomenological approach forces us to confront important ethical and political issues often ignored in discussions of diagnosis and treatment. Feminist psychologists in particular need to think more deeply about these issues, to avoid taking untenable moral positions and violating core assumptions about the right to define one’s own experience.

Points of View essays

Feminism and psychiatric diagnosis: Reflections of a feminist practitioner - Sally Swartz

Sexual dysfunction and paraphilias in the DSM-5: Pathology, heterogeneity, and gender - Robbie Duschinsky and Netta Chachamu

Social constructionist contributions to critiques of psychiatric diagnosis and classification - Eugenie Georgaca

Diagnosing difficult women and pathologising femininity: Gender bias in psychiatric nosology - Jane M Ussher

Lessons from the borderline: Anthropology, psychiatry, and the risks of being human - Rebecca J Lester

On the persistence of psychiatric diagnosis: Moving beyond a zombie classification system - David J Harper

Client subversions of DSM knowledge - Michael Guilfoyle

Articles

Industry’s colonization of psychiatry: Ethical and practical implications of financial conflicts of interest in the DSM-5

Lisa Cosgrove and Emily E Wheeler

The revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), scheduled for publication in May 2013 by the American Psychiatric Association (APA), has created a firestorm of controversy because of questions about undue industry influence. Specifically, concerns have been raised about financial conflicts of interest between DSM-5 panel members and the pharmaceutical industry. The authors argue that current approaches to the management of these relationships, particularly transparency of them, are insufficient solutions to the problem of industry’s capture of organized psychiatry. The conceptual framework of institutional corruption is used to understand psychiatry’s dependence on the pharmaceutical industry and to identify the epistemic assumptions that ground the DSM’s biopsychiatric discourse. APA’s rationale for including premenstrual dysphoric disorder in the DSM-5 as a Mood Disorder is reviewed and discussed.

Invoking and inscribing mental illness: A discursive analysis of diagnostic terminology in inpatient treatment planning meetings

Jessie Goicoechea

Critical feminist analyses document the power of psychiatric labeling, but less attention has been given to the social processes involved in giving and acquiring labels. Utilizing a discursive method based on conversation analysis, this study examined conversations among staff and with patients in treatment team meetings on an adult, involuntary inpatient unit of a state psychiatric hospital in the US, with a focus on how problem formulation and role negotiations are achieved and how diagnostic terminology figures into that work. In this brief report, extracts from treatment planning meetings with two female patients are presented to illustrate how diagnostic terminology steers conversations away from addressing the context of these women’s lives.

The DSM and its lure of legitimacy

Michelle N Lafrance and Suzanne McKenzie-Mohr

The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers a biomedical framing of people’s experiences of distress and impairment, and despite decades of criticism, it remains the dominant approach. This dominance is maintained not only by powerful corporate interests such as the pharmaceutical industry, but also through the everyday talk of people as they attempt to make meaning of themselves and their experiences. This paper explores how and why the DSM holds such cultural currency for individual speakers, and unpacks what is being accomplished in their taking up the language of psychiatric diagnosis. In particular, we argue that a biomedical construction of distress offers the lure, or promise, of validating persons’ pain and legitimizing their identities. However, we also argue that the very assumptions of biomedicine ensure that this promise can never entirely be fulfilled and, despite its lure, a biomedical construction of ‘mental illness’ all too frequently fails to protect individuals from delegitimation and stigma.

You may have followed the debates and controversies surrounding the upcoming release of the DSM-V and in particular the proposal to include “attenuated psychosis syndrome” as a diagnostic category. The DSM-V committee originally proposed including attenuated psychosis syndrome as a full diagnosis, but recently backed off in response to pressure from clinicians, researchers and members of the public. This debate is one of the tips of an iceberg called “early intervention in psychosis” (EIP).

A disclaimer: I am carrying out an ethnography of the EIP movement and I also work as a clinician in this field, so one might say that I am in the not-so-comfortable position of an embedded reporter.

If, like me, you consider early intervention to be one of the key sites where concepts and practices of contemporary psychiatry are being transformed, you may find particularly interesting the EIP movement’s most recent biannual meeting, the 8th International Conference on Early Psychosis, which took place this October in San Francisco.

The EIP movement, which took off in the 90s, had a soaring success worldwide, and in particular in English-speaking countries. The research output is growing exponentially (as this graph of publications by year indicates) and new clinics are popping up everywhere.

Conference highlights

The conference began with a plenary session delivered by John M. Kane: “The Early Treatment Of The NIMH Raise Initiative,” described an ongoing study testing the feasibility of delivering early intervention services in community-based, non-academic, “real-world settings utilizing current funding mechanisms” in the US. Until now, it has been  recommended that EIP treatments be delivered in specialized clinics, but this has proved complicated in context of the US health care system as well as in sparsely populated areas. Training clinicians in regular psychiatric clinics to deliver EIP was proposed as a cost-effective, realistic and sustainable option. The Q/A session highlighted some major issues with this proposed approach: 1) many interventions (such as group therapy) were sacrificed in the transition to “real world” conditions; 2) community clinics are “bare bones” and this could be both a study confounder and a hindrance to delivering intensive-enough EIP interventions; 3) if the study fails to show positive results because of “under-dosed culture of care”, this “might prematurely close the field” of EIP.

Sophia Vinogradov presented a paper titled “Neuroscience-Informed Cognitive Training In Recent Onset Schizophrenia Using Laptop Computer.”  This was an interesting glance into the potential future of psychiatric interventions: carefully crafted exercises, using neuropsychological knowledge from animal studies and contemporary technologies. I was relieved to learn that the cognitive training was superior to the control group (playing online games for 20 hours/week).

“Cognitive Behavior Therapy Without Antipsychotics: Is It Effective Across The Continuum Of Psychotic Disorders?” presented by Tony Morrison, was a major breech in the usual discourse about the inevitability of antipsychotic medication in psychosis. This presentation reviewed several studies showing robust and sustained improvements in patients refusing medication, but accepting Cognitive Behavioral Therapy. The presenter took the time to explain that he was not against medication, but against the overreliance on antipsychotics and a lack of choice or imposed choices.

Davis Shires received the Richard Wyatt Award in recognition of his work in reforming psychiatric services in the UK – the only country to require specialist EIP services for the whole country. We learned that Dr Shires was motivated by his personal experience with psychiatric services as his daughter developed psychosis in the 1990s. He mentioned a meeting with Pat McGorry (the former head of the most influencial EIP clinic) in Melbourne as a key element in his journey of improving psychiatric care. He urged the field to pay more attention to the “body” – especially to medication side effects.

Finally, Pat McGorry presented “Early Intervention In Psychiatry: Lessons From Psychosis,” reviewing the proposal to expand the principles of EIP—particularly the idea of early intervention—to all of psychiatry, using concepts borrowed from other medical fields (e.g. “staging” coming from cancerology – see video from another conference for details). This was proposed as the next development of the movement, and is already promoted by a dedicated journal (Early Intervention in Psychiatry) and a Youth Mental Health Program.

Remarks

The initial motivations behind EIP were a discontent with the quality of care in traditional psychiatric settings and the hope that new, better treatments (not only medication, but also psychotherapy and social interventions) would improve the lives of persons suffering from psychosis if given sufficiently early (e.g. during a “critical period”). Social scientists might immediately notice EIP’s potential anti-psychiatric flavor and its daring claims of prevention. Indeed, psychiatry was not much into the prevention business, even less when dealing with schizophrenia or psychosis. After the initially focused claim of secondary prevention (i.e. halting or slowing the progression/relapse of psychosis), EIP began exploring primary prevention (i.e. protection from developing psychosis – the field of the “attenuated psychosis syndrome” or prodrome).

The movement is scaling up, leaving small, research-based university specialized clinics for “the real world” – hence the subtitle of this year’s conference: from neurobiology to public policy. Naturally, the critique of “typical” psychiatric care seems to recede as EIP advances.

Finally, the human basis of this movement is also expanding and changing: a new generation of clinicians, researchers and administrators arrived, happy to be part of this new, trendy, dynamic movement, but not necessarily sharing the motivations of the founders.

Given that the early intervention in psychosis movement is arguably on the forefront of the expanding borders of psychiatry, it is interesting to observe how it changes internally and how the rest of society responds to it.  For the moment, the DSM-V committee backed-off and removed attenuated psychosis syndrome from the well established, but I bet EIP researchers are considering the fight only postponed until the next revision of DSM.

Daniel Buchman and his colleagues (2012)–all members of the new Neuroethics Core at the University of British Columbia–present analyses of a qualitative study designed to explore the implications of potential future advances in neuroimaging (e.g. imaging-based biomarkers) from the perspective of individuals with diagnoses of depression or bipolar disorder.  Participants’ narratives reveal relatively strong convictions that such advances might both increase the socio-medical “legitimacy” of their disorders, and deflect stigmatizing conclusions regarding personal responsibility and culpability. In other words, neuroimaging promises to reframe psychiatric illnesses as unmediated physical insults which, like breast cancer or neurological disease, are understood as external to the self and which the ‘sufferer’ is made to endure but for which she bears no responsibility.  As Buchman and his colleagues point out, however, though such blame-deflecting narratives have been advanced by a variety of private and clinical interests, the evidence from both population-based and experimental studies suggests that “biomedical” or “biogenetic” explanatory models in general have not only failed to ameliorate, but in some cases actually worsened, public stigma (e.g. Pescosolido et al., 2010; Rüsch et al., 2010; Schomerus et al., 2012).  Participants’ perspectives on neuroimaging may thus reflect the internalization of select politically-motivated perspectives on stigma change (e.g. pharmaceutically-driven linkages between destigmatization and predominantly “neurochemical” explanations of depression) rather than the real-world impacts of biogenetic attributions on stigma change.

Even here, however, existing research suggests a complex picture.  In Chicago, Nicholas Rüsch and colleagues, for example, have explored the impact of genetic and neurobiological causal attributions on both explicit and implicit attitudes using a mental illness-specific adaptation of the implicit attitudes test (IAT). Pace the effects fantasied by Buchman’s interviewees, Rüsch (2010) found that service users who strongly endorsed both neurobiological and genetic causes generally affirmed a desire for greater social distance from other individuals with psychiatric diagnoses, and scored significantly higher on implicit measures designed to tap “guilt-prone [mental illness-related] self-concepts” (though, importantly, they did not explicitly endorse higher levels of self-responsibility). Although the authors attribute these findings partly to “genetic essentialism” (i.e. the belief that biogenetic changes implicate the individual’s “self” in an even more intrinsic and permanent way than psychosocial causes), it seems equally possible that those individuals most internally troubled by their own agentic implication are in turn more likely to attempt—ultimately unsuccessfully—to deflect this guilt and shame through the explicit and self-consciously public endorsement of more strongly biogenetic ontologies. Intriguingly, the researchers identified a very different pattern of correlations in members of the general public: endorsement of genetic (but not neurobiological) causes strongly correlated with greater desired social distance form individuals with schizophrenia but lower levels of both implicit and explicit blame.  For patients, in other words, explicit endorsement of a biogenetic model was found to correlate with self-blame and guilt, while those non-patients who most strongly endorsed genetic factors were less likely to blame individuals with psychiatric diagnoses but more likely to report discomfort and a desire to avoid social interactions.

A further provocative, if not unexpected, theme of Buchman and colleagues’ paper is the unmistakably visual materialism iterated in participants’ comments. Above all, that is, these service users emphasized the visual immediacy of the neuroimage (rather than the human science behind it) in prospectively persuading the public of the (material and physical) veridicality of psychiatric disorder. Although neuroimages, as the authors underscore, are in fact among the most mediated of contemporary anatomical artifacts, popular assumption remains that such technologies precisely bypass suspect forms of ‘mental’ interpretation, allowing the brain to directly “speak” or show itself.  And here—a theme I will return to–we arguably find less evidence of a paradigm shift occasioned by neuro-narratives, than a contemporary reiteration of the historically entrenched binding of visual (re)presentation and medico-anatomical truth. Laqueur (1990), for example, identifies the origin of the conviction that “Truth and progress lay not in texts, but in the opened and properly displayed body” as far back as the 16^th century, exemplified by Vesalius’ monumental 1543 frontspiece to De humani corporis fabrica (p. 70).

Where Buchman’s work helps unpack the projected or fantasied consequences of ‘advances’ in neuroimaging, Felicity Callard and colleagues’ (2012) recent paper explores specific deployments of “gene talk” in interviews with (non-user) family members of individuals diagnosed with schizophrenia.  Painstakingly attentive to the discursive and nonverbal-affective tensions embedded within participants’ narratives, Callard and colleagues’ analysis highlights family members’ sometimes vigorous invocation of causal genetic mechanisms in an effort to mitigate personal responsibility, but also the ultimate (at least partial) failure of these efforts. Some sense of self-blame or responsibility appears difficult or impossible to shake, in spite of the public legitimacy of explicitly bio-expiatory frameworks.

In the course of interrogating these positions, the authors also help illuminate the ‘real world’ messiness of genetic discourse.  In addition to the ways in which participants’ narratives are complicated by concepts stemming from epigenetics and the gene environment interactions literature, these narratives also turn our attention to and even reinforce the irreducibly social nature of the “new” kinship ties between affected (trans-generational) family members.  In the same stroke, strange or eccentric relatives are newly pathologized (relative to normal kin) but also “normalized” through the (re)establishment of common behavioral bonds:  so-and-so’s schizophrenic daughter is now retrospectively linked, for instance, to a “mad” great aunt, a second cousin who was a recluse, an alcoholic grandfather who died under mysterious circumstances. These complications, in turn, raise further questions regarding agency:  is a mother responsible for not recognizing “early warning signs” in her son, consistent with a relative’s behavior, or even overlooking a family history of mental illness altogether? Do “bad genes” implicate a larger trans-generational family unit in a way irreducible to any given individual, and yet for which all members nevertheless retain some unspoken (perhaps only implicit) culpability?  Does gene talk ultimately decrease responsibility or simply displace it to other spheres of reproductive and parental decision-making?

Without any claim to having comprehensively reviewed Buchman and Callard’s papers, let me now turn to a few select implications.

(1)  The myth of the biopsychosocial model.  Although psychiatric textbooks, by and large, almost ubiquitously reference “biopsychosocial” models of psychiatric disorder, such models mostly function, as critics have pointed out, as disciplinary “shibboleths” or empty “catchphrases” rather than substantive attempts to deconstruct relationships within and across domains (Markova & Berrios, 2012; McLaren, 2002). Or, as philosophers are more likely to put it, we might say that we simply haven’t solved the “brain-mind problem”.  Given these academic difficulties—effects, at least in part, of the resilience of physical-mental dualism(s) in Euro-American culture—it should come as no surprise that members of the “general public,” forced to negotiate the complexities of causality in the context of increasingly complex iterations of neuroscience, genetics and critical social research, are also unable to do so in any clear or straightforward way.  Buchman’s and especially Callard’s work, however, arguably underscores an even greater difficulty: not the difficulty of integrating or relating diverse factors that, in isolation, are clear and distinct, but rather the dilemma of parsing distinctions between “categories” that cross and re-cross to the point of semantic indeterminacy.  What “sense” is there in attempting to relegate the neuroimage to the domain of either the social or the biological, for example, or the lineages constructed on the basis of retrospectively identified pathological ties?  Or as my colleague Summer Schrader likes to point out, the dietary changes or alternative (“physical”) therapies recommended by critics of “biomedical” approaches to mental distress?  What would the purpose be of attempting to determine whether the epigenetic changes occasioned by childhood abuse categorically differ in terms of their social or biological nature from the neurobiological trauma occasioned by a car accident?

Arguably then, following my interpretation of Callard’s lead, we might instead emphasize the often tacit sociopolitical motivations that prompt us to deploy this or that explanatory category (e.g. the social, psychological, genetic, or neural) or cultural script in particular circumstances and not others not because of the veridicality of the category employed but because of its social, cultural and moral effects.

(2) Agency. Although the challenge facing us all is undeniably multidimensional, I want to suggest that possibly more important—more fundamental, more impactful–than the question of where we can or can’t locate the ‘cause’ of a given condition or experience, is the question of human agency.  Ultimately, that is, the distinction between the biological, the psychological and the social is perhaps less important than the extent to which we or they (service user, family member, member of society), can or should be held responsible, and are or are not, in terms of our/their personality and self, “synonymous” with (or separable from) ‘our’ or ‘their’ disorder.   Undeniably, certain concepts have been culturally vested with specific agentic or expiatory qualities (e.g. the biological qua external insult), but this does not mean, in practice, that these qualities are in any sense stable or guaranteed. This is clear in the construct of “genetic essentialism”: even a disorder that we did not ‘cause’ may so thoroughly consume us that our immediate agency is implicated, even though our “prior” or originary agency is not.  Agency is thus arguably one of the most important, and yet most under-researched, trans-disciplinary issues in the domain of psychiatric disorder.

(3) Politics. Finally, in interrogating the politics of these themes, the work of Buchman, Rüsch, Callard and their colleagues reminds us that we should not forget the frequent divergences between fantasy and ‘reality,’ projection and experience, internal doubt and public articulation, the implicit and the explicit.  For instance, we might note the disconnect between the similarities Callard (2012) identifies between ‘everyday’ users and family members’ explanatory narratives, and the often intense public disagreements between political advocacy groups historically dominated by “family members” (e.g NAMI in the States) versus user/survivors regarding the origins and nature of psychiatric experiences.  Perhaps regardless of any of our (conscious or unconscious) private sentiments, that is, political pressures and motivations often force us to adopt more dogmatic positions, positions that, I tentatively maintain, may again have more to do with the group-specific implications of different (typically significantly simplified) ‘causal attributions’ with respect to agency and responsibility than to ideology or perceived ‘truth.’ (E.g. “schizophrenia is a brain disease that in no way implicates mothers” or “schizophrenia is not a brain disease and therefore cannot be used to justify the infringements on individual freedom, rights, or autonomy so often based in putatively ‘neurological’ anosognosia.”)

In moving forward, then, my brief recommendations are that we (1) recognize the complexities and importance of agency, whether in the context of internal ‘symptom management’, interpersonal ‘explanation’ or public discourse; (2) attend to the popular, political and psychodynamic motivations behind and effects of the deployment of given cultural scripts as separate from their philosophical or scientific ‘semantics’; and (3) grapple with not only the experiences participants report in qualitative investigations, but also, ala Callard, their unspoken and/or affective ‘communications,’ as well as the broader sociopolitical pressures that push public discourse, often regardless of the nuance of the individual experiences that research participants might report, in particular, often vexed, directions.

References

Buchman, D, Borgelt, E., Whiteley, L. & Illes, J. (in press). Neurobiological narratives: experiences of mood disorder through the lens of neuroimaging. Sociology of Health and Illness. doi: 10.1111/j.1467-9566.2012.01478.x.

Callard, F. (2012). Schizophrenia: Does Talk of Genes and Brains Really Stop a Mother’s Blame? Huffington Post UK, September 9, 2012.

Callard, F., Rose, D., Hanif, E-L., Quigley, J., Greenwood, K. & Wykes, T. (in press). Holding blame at bay? ‘Gene talk’ in family members’ accounts of schizophrenia aetiology. BioSocieties.

Laqueur, T. (1990).  Making sex: Body and Gender from the Greeks to Freud. Cambridge: Harvard University Press.

Marková, I. S., & Berrios, G. E. (2012). Epistemology of Psychiatry. Psychopathology, 45(4), 220-227.

McLaren, N. N. (2006). The myth of the biopsychosocial model. Australian And New Zealand Journal Of Psychiatry, 40(3), 277-278.

Pescosolido, B. A., Martin, J. K., Long, J., Medina, T. R., Phelan, J. C., & Link, B. G. (2010). “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. The American Journal Of Psychiatry, 167(11), 1321-1330.

Rüsch, N., Todd, A. R., Bodenhausen, G. V., & Corrigan, P. W. (2010). Biogenetic models of psychopathology, implicit guilt, and mental illness stigma. Psychiatry Research, 179(3), 328 332.

Schomerus, G. G., Schwahn, C. C., Holzinger, A. A., Corrigan, P. W., Grabe, H. J., Carta, M. G., & Angermeyer, M. C. (2012). Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 125(6), 440-452.

Nev Jones is currently a psychology doctoral student at DePaul University in Chicago with an extensive background in continental philosophy and enduring interests in the intersections of psychiatry, psychological anthropology, critical neuroscience and cultural theory.  See her research website here.

John Gever of MedPage Today, has done a terrific summary of the proposed changes to the DSM (“DSM-5: What’s In, What’s Out“).

The umpteenth person just described the DSM-5 process to me as a major rehaul. Is it? Aside from the changes in how we want to sort the world of persons living with psychiatric disorder (and everyone would agree it’s still a flawed taxonomy as long as we don’t understand cause), there are two interesting developments that presage better things to come for the next next edition.

The first is the inclusion of cross-cutting dimensional assessments ranging from normal to pathological (consider Tanya Luhrmann’s work on the experience of “hearing voices” in her new book, When God Talks Back). As Gever explains:

These are indicators of severity for certain symptoms. They may be common “cross-cutting” features that appear in conjunction with many disorders, such as suicide risk and anxiety. Or they may be specific to a particular disorder, such as the frequency of flashbacks in PTSD.

The second is the use of biomarkers for sleep-related disorders like narcolepsy.

Many sleep-wake disorders in DSM-5 will require polysomnography for a diagnosis. Also, narcolepsy is set to become narcolepsy/hypocretin deficiency, with the latter condition diagnosed on the basis of hypocretin measurements in cerebrospinal fluid.

Otherwise, as historian Edward Shorter argues in a 5/9 Scientific American blog post nothing has essentially changed.

According to Shorter, the main difficulty is that the principal diagnoses of psychiatry are “artifacts.” He goes on to discuss major depression, schizophrenia, and bipolar disorder, specifically. All of these disorders are loosely grouped clusters of symptoms for which we currently lack causal explanations. (The interesting exception is melancholia, which doesn’t appear in the current DSM but which may well be an actual category of illness rather than composed of something that can be ranged along a continuum.)

This matters because, Shorter writes, “[y]ou can’t develop drugs for diseases that don’t exist.”

Constance A. Cummings, Ph.D., is Project Director of the non-profit The Foundation for Psychocultural Research, which supports and advances interdisciplinary research and scholarship at the intersection of brain, mind, culture, and mental health and illness. She is co-editor (with Carol Worthman, Paul Plotsky, and Dan Schechter) of Formative Experiences: The Interaction of Caregiving, Culture, and Developmental Psychobiology (New York: Cambridge University Press, 2010). She received her doctorate in theoretical linguistics from New York University.

I came across this ad in a 1966 issue of JAMA. This isn’t at all my area of research, but I thought the ad was quite evocative of the changes that have occurred in psychiatry and mental health care over the past thirty years.

Because we now think of Ritalin as a drug used to curb hyperactivity or to focus the abnormally dispersed attention of ADHD kids, it is striking to see that at this time it was being marketed as a kind of mild anti-depressant for housewives. Given that the drug is a stimulant, this makes sense, and as several accounts of the history of ADHD have pointed out, it was originally the effectiveness of stimulants like Benzedrine in calming hyperactive children (during the 1960s the diagnostic term often used was “hyperkinetic syndrome”) that clinicians found surprising and counterintuitive.

The ad also uses a vague pre-DSM-III diagnostic language: “chronic fatigue that depresses and mild depression that fatigues,”!

I also find striking that—unlike what you find in contemporary ads for anti-depressants—the woman in this ad doesn’t look particularly happy in the “after” shot. She’s just steadily peeling away, fulfilling her housewifely duties, looking almost as miserable as she does in the first image. It almost lends itself too easily to the critique made of Ritalin in connection to ADHD since the 90s: that it is used as a means of fostering self-disciplining subjects capable of fulfilling expected social roles.

Andy Lakoff and Ilina Singh have both written accounts of the development of ADHD as a diagnostic entity, and Singh’s article in Science in Context gives us a nice interpretation of how this early marketing of Ritalin to women may have paved the way for its use with children:

“Ciba played an important role in the promotion of Ritalin within the medical industry through paid clinical research, advertising in physicians’ journals, and direct sales strategies…. It is more difficult to establish Ciba’s role in promoting acceptance of Ritalin within the domestic realm. It can be argued, speculatively, that Ritalin benefited from a shift in public understanding of mental illness, promoted in part by the creation and marketing of drugs for a nation of “worried well.” In particular, the success of anti-depressant drugs may have contributed to mothers’ acceptance of Ritalin for relatively common behavior problems in boys. The pharmaceutical industry and the medical profession probably targeted women for anti-depressant diagnoses and treatments… and women accustomed to drugs for their own relatively common problems may have been more likely to accept Ritalin for their sons’ problems,” (Singh 2002: 592-3)

For more on the history of ADHD see:

Lakoff, A. “Adaptive Will: The Evolution of Attention Deficit Disorder.” Journal of the History of the Behavioral Sciences 36, 2 (2000): 149-169.

Singh, I. “Bad Boys, Good Mothers, and the “Miracle” of Ritalin.” Science in Context 15, 04 (2002): 577-603.