REVIEW
THE MEDICALIZATION OF LIFE THROUGH THE DIAGNOSTIC INFLATION: is it possible to revert this condition?
By Gleiciene
Gomes de Araújo
Fluminense Federal University (UFF)
Santo Antônio de Pádua, RJ, Brazil
FRANCES, Allen. Voltando ao Normal: como o excesso de diagnósticos e a medicalização da vida estão acabando com a nossa sanidade e o que pode ser feito para retomarmos o controle. Rio de Janeiro: Versal Editores, 2016.
DOI: https://doi.org/10.22409/mov.v7i15.42536
The high diagnostic inflation lived in the current world makes drug interventions increasingly possible which are often performed in an imprudent manner. Thus, Allen Frances, a psychiatrist who led the team responsible for preparing the fourth edition of DSM (Diagnostic and Statistical Manual of Mental Disorders), writes this book as a great criticism to the fifth edition of the DSM, to the misuse of this manual and, above all, to our medicalized society.
The book consists of ten chapters divided into three main parts. In the first one, composed of the first three chapters, the author starts his search for the definition of what would be the "normal". He uses the meanings of the dictionary and uses philosophy, statistics, medicine, sociology, and the Freudian theory in an attempt to understand such a concept.
Given this, Allen Frances concludes that, as difficult as defining what is normal, it is determining what is "abnormal". To him, this conflict exists, because defining normality is beyond our possibilities, what brings us closer to what Foucault (2001) has already demonstrated: the "normal" is modified over time, that is, as well as the truth, he is transformed according to time, space and the current power relations.
Even without the definition of what would be "normal", Frances states that normality - whatever it may be - has been losing its place in society as the psychiatry creates simpler mechanisms to determine diagnosis or to accept the alleged "abnormal".
Still in the first part of the book, the author historically contextualizes the emergence of psychiatry from the oldest societies to professional practice in the current world. At this moment, it is interesting to realize that only after the creation of psychoanalysis the psychiatry began to expand its degree of performance, failing to treat only mental patients considered more serious.
Finishing the first part, the author brings information about the construction of the DSM. The manual had been created in the year 1952 and, because it was elaborated predominantly in the psychoanalytic model, had as main focus the treatment of the sick. Only in its third edition does the focus shift to diagnosis as a means of standardizing psychiatric patients. It so happens that, for this, general similarities are created and individual differences are ignored.
In the review of the third edition of the DSM, the situation seems to get worse, as the definitions of diagnosis become increasingly vague, which makes it possible to increase the consumption of medicines.
When talking about the DSM IV, an edition led by the author himself, the concern with the manual's continuous misuse is noticeable, which should serve only as a guide and not as the only source of information. Thus, Frances blames himself for not warning more sharply in the manual the risks of overdiagnosis.
In the second part of the book, Frances endeavors to demonstrate the diagnostic changes over time, calling them "psychiatric fads". He includes three chapters that aim to differentiate the fads of the past, present, and future, outlining some psychiatric "diagnoses" which made sense in a certain period and certain places.
In comparison with the present, the author concludes that the fads of the past were very restricted to certain environments because the information did not flow as easily as today. He also points out that the creation of the DSM boosted the globalization of psychiatric fads, because, with a manual to guide diagnoses, it gets easier to create global patterns.
Still on the fads of the present, the author brings some diseases as a highlight but mainly points out those that reach the child audience as a source of greatest concern. The Attention Deficit Hyperactivity Disorder (ADHD) and autism are the most frequent diagnoses, despite the existence of others also very incident. However, according to the author, these two happen to have more prominence, because the way the diagnosis is done allows more children to fit the listed requisites.
Frances also warns about the danger of diagnosing children so early, because, as every subject carries its individualities, it is necessary that whoever does the diagnosis is aware that, many times, the child is only immature or needs educational guidance or psychotherapy, for example. In this case, it is essential to diagnose or enter with medication only when all these hypotheses are discarded.
Another important point raised by Frances is that the school itself helps to highlight those diagnoses, demanding, sometimes, those responsible to take the children to the doctor for the final verdict.
The author includes the DSM5 as a major bet on diagnostic inflation and the construction of new fads in the future, mainly with the introduction of the Disruptive Mood Dysregulation Disorder (DMDD), which, for Frances, is the transformation of peeves into mental disorders. Lima (2016) also highlights the change made in the ADHD diagnosis in DSM5, increasing the possibility of the disease in three years, which also increases the number of diagnosed patients.
It is worth remembering that this change of possibilities of "being" in diagnostics creates mechanisms that allow the pharmaceutical industry to gain space and profit with diseases that should not have such prominence. Moysés and Collares (2014) point out that characters like Menino Maluquinho and Mafalda would not have enough space in this current medicalized society. since their irreverent ways of acting would be treated as diseases and, because they are medicated, they would not be able to build their stories.
Following this thread, it is also worth remembering that we could incur what Lima (2016) called a normal child syndrome, in other words, it is when we expect a child to behave as if they were not infantile beings, diagnosing what is the nature of their age.
The third and final part is dedicated to trying to devise a way to "go back to normal" as the book's title suggests. So, Frances uses the last four chapters with this goal. Thus, the author concludes that the misuse of legalized drugs is as prejudicial as the use of illegal drugs, but, even so, they do not suffer the social reprisal associated with those drugs. He believes that, in order to contain diagnostic inflation, it is necessary to have a policy interested in this, with the economic power of the pharmaceutical industry being the major obstacle for these practices to be adopted by the responsible agencies.
Then, Frances defends that the creation of a diagnosis should be submitted to a process as careful as those related to medications. Thus, it should be done alongside a team of specialists from the fields of mental health, health economics, criminalistics, and education. Only then would the diagnoses be less likely to be poorly formulated and misused.
In order to make a diagnosis, Frances believes that it should be several medical appointments until its validity can be verified. Freud ([1909] 1996) had already pointed out to us the great mistake of diagnosing only with the first impressions brought by the patient, due to the unsteady character of the subjects' subjectivity. We happen to live in a capitalist world and, because of that, we're managed by the capital. Inserted in this context, doctors may end up performing the appointments briefly, relying on superficial and quick questions, which can result in a misdiagnosis. In addition, we have the power of pharmaceutical industries that creates countless mechanisms to make doctors prescribe their medicines.
Considering all these reflections, the author asks us the following question: how to evade the diagnostic bubble? Frances cites investigative journalism and the media as great allies to slow the spread of marketing by the pharmaceutical industries by publicizing the dangers of this inflation.
In order to demonstrate how making a diagnosis is a complicated topic. Frances gives examples of poorly made diagnoses, which have led to major losses and inconvenience. He also exemplifies cases in which the diagnoses were made successfully and they made all the difference in the subject's life.
Lastly, we understand that this book brings an important conclusion when Frances makes it clear that diagnoses are not society's greatest enemies, but their misuse is. Especially because, through professionals inserted in a logic of medicalizing power, barriers are created so that the practice of diagnosis is carried out with parsimony and responsibility, thus making it difficult to “return to normal”.
References
FOUCAULT, Michel. Os anormais: Curso no Collège de France (1974 – 1975). São Paulo: Martins Fontes, 2001.
FRANCES, Allen. Voltando Ao Normal: como o excesso de diagnósticos e a medicalização da vida estão acabando com a nossa sanidade e o que pode ser feito para retomarmos o controle. Rio de Janeiro: Versal Editores, 2016.
FREUD, Sigmund. Análise de uma fobia em um menino de cinco anos (1909). In:
FREUD, Sigmund. Obras Psicológicas Completas de Sigmund Freud. Rio de Janeiro: Imago, Ed. Standard Brasileira das Obras Completas, 1976. v. X, pp.11-154.
LIMA, Rossano Cabral. Psiquiatria Infantil, medicalização e a Síndrome da Criança Normal. In: Comissão de Psicologia e Educação do CRP-RJ (Org.) Conversações em Psicologia e Educação. – Rio de Janeiro: Conselho Regional de Psicologia 5ª Região, 2016, pp.61-72.
MOYSÉS, Maria Aparecida Affonso; COLLARES, Cecília Azevedo Lima Medicalização do comportamento e da aprendizagem: a nova face do obscurantismo. In Viégas, L. S. [et. al.] (Org.). Medicalização da educação e da sociedade: ciência ou mito? – Salvador: EDUFBA, 2014, pp.21-43.
ABOUTH THE AUTHOR
GLEICIENE GOMES DE ARAÚJO holds a master’s degree in Teaching from the Fluminense Federal University (UFF), a professor at the Fluminense Federal University (UFF) and a member of the Center for Intersectional Studies in Psychology and Education (NEIPE/UFF).
E-mail: ggomes@id.uff.br
Accpted: 24.05.2020