- Historic Sites
How Prozac Slew Freud
In the past hundred years psychiatry has come full circle: Psychoanalysis lost; medicine won
September 1998 | Volume 49, Issue 5
In addition, the new biological psychiatry still has the capacity to shoot itself in the foot. One tiger pit into which it can fall is the proliferation of new diseases. Whenever you hear about a new disease, a warning light should go on in your mind, for there really is very little new under the sun. Yet in child psychiatry, for instance, so-called attention deficit disorders have become all but ubiquitous. The classrooms in well-to-do neighborhoods are now rife with children who have received diagnoses unknown thirty years ago, such as attention deficit hyperactivity disorder (ADHD), children who every morning must take their medication, usually a Novartis product called Ritalin (methylphenidate). Generally the problem falls in the Tom Sawyer band on the spectrum of standard child behavior, affecting normal active kids (usually boys) whose teachers are tired of their antics and whose parents have accepted a diagnosis urged on them by the school social worker. A psychiatrist or pediatrician often confirms the diagnosis because it’s the simplest way of dealing with the parents’ anxiety.
Is there really such a disease as ADHD? Yes, in that a small number of these children do have a genetically based problem with hyperactivity. No, in the sense that the so-called disease is virtually unknown elsewhere. (Try asking a British psychiatrist what he or she thinks about ADHD.) Evidence of the culture- specific nature of the epidemic: The United States consumes 90 percent of the world’s Ritalin.
Trauma has been another trap for the new psychiatry. In the 1970s posttraumatic stress disorder (PTSD) was first articulated by a group of Vietnam veterans, and it rapidly disseminated from the narrow world of unhappy vets to the wide world in which stress and unhappiness are as common as grass. Suddenly the normal frictions and disappointments of life became a psychiatric illness, and PTSD counseling a growth industry. Yet even an event as stressful as the Holocaust produced no particular pattern of psychiatric illness in its victims; I follow on this point the wisdom of Herman van Praag, former chair of psychiatry at the Albert Einstein College of Medicine and himself a Holocaust survivor. It is unrealistic to claim that watching scary movies on television can produce PTSD in children.
American society seems to crave psychiatric diagnoses. The positive side of this is that psychiatric illness is being destigmatized; the bad news is that the normal heartburn of living is being medicalized. When the burden of self-consciousness is pathologized, psychiatrists are called on to do things for which they are not actually trained. In psychiatry school you aren’t taught to help people deal with unhappiness, which tends to flow from the structure of life; you’re taught to look for the side effects of medication and prevent the patient’s lithium from interacting with his cardiology drugs. You’re trained to deal with such psychiatric symptoms as depression, anxiety, obsessive-compulsive behavior, and, in the overmedicated elderly, delirium. And with the new biological psychiatry, you learn to perform these tasks very well.
But American society will be disappointed if it calls upon psychiatry to deal with children who are out of control, adults who cannot keep relationships together, and drivers who experience “road rage” when somebody tailgates them. It is psychiatry’s alliance with the neurosciences, a triumphant revival, that has given it the ability to deal effectively with real psychiatric illness. It is owing to the long hegemony of psychoanalysis that we somehow expect from psychiatry much more.