Wednesday, October 03, 2007

Do disorders come in natural kinds?

There has been a debate in philosophy for since forever about whether there are natural kinds. Philosophers who think that there are not natural kinds often call themselves "nominalists." "Nomos" is Greek for "name" and monimalists argue that our perception that the world comes in categories is entirely dependent upon our words.

It makes a lot of sense if you think about bodies of water. The name of my home town is an American Indian word which I am told means, "large flat body of water." It can refer to a lake or a bay. We have words like creek, river, stream, not to mention pond and lake. The world just has water. We divide it up according to our interests and then we think it comes that way.

Of course a true nominalist thinks that nothing comes pre-categorized, but in order to explain to you what I have been wondering, we need to assume that some things do come in natural kinds (like elephants and giraffes) and some things don't (like musical instruments).

We no longer regard consumption as a natural kind. Years ago if you had a chronic lung condition, you could get diagnosed with consumption. If we could go back in time we would diagnose most of the people with tuberculosis, but a good chunk of them would be people with bronchitis, pneumonia, asthma, emphysema or lung cancer.

Everyone with me? Consumption, as a kind (natural or nominalist), is not something we recognize anymore. If someone were to go back in time and tell doctors that there was no such thing as consumption they would be stunned and show us all the sick people. It might take a while to explain we weren't denying the existence of the sick people, just the category. By the way, if I'm wrong about consumption, I don't really care. This is set up.

And I wonder how many of the things in the DSM (pick your number) will be regarded as "real" in one hundred years.

There is just so much cross-over in symptomology. Disorders/conditions are described and there is no definitive test to figure it out. Consider all the forms of autism and FASD, not to mention OCD, ODD, RAD, ADHD, ADD, borderline personality disorder, narcissistic personality disorder, social anxiety disorder, and.. you get the idea.

It seems likely to me that someday we will regard ADD and ADHD as symptoms not diagnoses. I could really be wrong, but I think so. And I wonder if we will think that FASD is "real" or if we will decide that fetal alcohol exposure can cause damage to different parts of the body. We know that mothers who have Rubella (German Measles) when pregnant can have babies who have hearing, vision, heart, and cognitive impairments. We don't however think that there is such a thing as "Rubella Spectrum Disorder."

I have all this going through my head as I am getting ready to schedule Frankie for his neuropsych evaluation. The hope of many of us is that he will go with his file which includes at least four different disorders (two of which are generally considered to exclude each other) and come out with one. It is not clear that he has ever had a complete evaluation like the one he is going to get. He has had IQ tests, aptitude tests, and been diagnosed with various sorts of things based upon behaviors that he exhibited at the time, behaviors that might have been entirely reasonable responses to very unreasonable living conditions. (Did you know not so very long ago at least one physician diagnosed slaves who kept running away with Drapetomania? Of course the word just means "manic runaway slave" but the point was that some people regarded the reasonable behavior of running away from salvery as a psychiatric disorder.)

So, after this evaluation will Frankie be determined to have Asperger's, FASD-ARND, or will be told just that he is a sweet, clumsy kid with ADD?

And will whatever they tell us be really helpful? It will certainly have a great affect on the sorts of services I can get for him, but will it be real? Is it based on truth?

Or is it just the category to which he will be assigned. "Nope, too short for a mountain -- you are really a hill."


  1. This sure sounds a lot like what we went through with "Danielle's" psych exam. We were hoping to get something meaningful out of it, but only came away with jibberish. We were told she needed certain services, but nothing has been done to actually obtain those services for her. We aren't allowed to make the referrals ourselves.

    So the psych told us it was a mountain, or maybe a hill, or maybe something that could be bulldozed, but he couldn't make any predictions, and we don't know.

  2. I totally agree with you!


  3. I've been trying to find the time (and the words!) to say this for days now and kept failing. And now you thought of it yourself! But I will try to explain what I think anyway.

    (A word of warning: it would take me days to write this down properly, as I would like it to be written down. This is somewhat stream of consciousness and it might or might not make sense.)

    ASD is an umbrella term. It covers all sorts of cases with similar symptoms; and a lot of people (though perhaps not the people who wrote the DSM) think that there are more than one causes that could result in those symptoms. There are children who are "cured" of "autism" after a few weeks of a gluten free, casein free diet. There are children whose symptoms are caused by other severe allergies. And there are children for whom those things don't seem to make a difference.

    In general there are two big threads in autism, apart from the things mentioned above: the sensory integration thread and the autism-proper thread, if that makes sense.

    Some people think all autism is just a very bad case of Sensory Integration Disorder -- as in, you too would be hitting your head against the wall if you couldn't feel where your body was, where you ended and where the world began! They think that working on integrating the senses will sort everything else out too.

    And there are those who think that this thing called autism is a thing in itself and is defined more or less as the inability of the brain to process information in certain ways.

    Now if you believe that autism is a thing in itself, and I do, you have to realise that Aspergers is only a small part of the spectrum. If you think of the spectrum having the size of a lake, Aspergers would be a smallish island close to one shore. It just that this particular island happened to be studied by somebody and so it got his name and acquired a status as a free-standing diagnosis.

    What I'm trying to say is the diagnostic criteria for it are not that important. In fact I think they're all wrong -- they're just symptoms, sometimes symptoms of symptoms even. But I digress.

    If you want a good indication of whether Frankie has Aspergers or not (but only an indication!) look to see if he looks at people's faces to get information about things. If you were frowning because you can't possibly hear another minute of talking about WoW, would he be able to tell? And, even if he can, does he look out for this sort of information? He might be able to tell you are angry, but does he check to see how you feel when he's talking with you? Does he do it consistently?

    Anyway. I don't know very much about all the other diagnoses you mentioned but it sounds very likely to me that the situation with those is similar too. Especially FASD as the symptoms are so broad. And there are people who think that ADHD/ADD are on the autistic spectrum too, and I can see where they're coming from.

    All in all, I think you're right...

    PS Oh, yeah, I'm a lurker... hello!

  4. lord, i take a few days off and all sorts of fun stuff happens! glad all is still exciting. when i took DSM in grad school the very first thing the proff told us was, 'nobody can have every disability in that book! so when you start reading it and diagnosing yourselves with everything you see slow down, it's just not possible.' the book is a guide at best. 'the diagnosing criteria is x of y symptoms. 'a pervasive pattern of X, Y and Z, beginning by early adulthood and present in a variety of cantexts, as indicated by four (or more) of the following: followed by any number of symptoms.' i've looked up asperger's and if you like i'll send it to you by email. looking at the criteria i don't really think that frankie fits within the guidelines. well, that's the news from the deep south, catch you later.


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