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Tuesday, April 28, 2015

Dissent, Mental Illness, and the Sovietization of American Psychiatry

In a 1959 speech, Nikita Khrushchev made the following remark:
Can there be diseases, nervous diseases among certain people in the communist society? Evidently there can be. If that is so, then there also will be offenses which are characteristic of people with abnormal minds. To those who might start calling for opposition to communism on this ‘basis,’ we say that now, too, there are people who fight against communism, but clearly the mental state of such people is not normal.
After Khrushchev’s speech, Soviet psychiatrists immediately set about trying to identify, and "treat" (with drugs and institutionalization), all the mentally ill “communism deniers.”

Haldol was the chief antipsychotic used in Soviet "political hospitals." Early ads for Haldol emphasized cooperation and control. Its use in the U.S. has declined in favor of risperidone and other "atypicals." Click to enlarge.

The groundwork had already been laid: In 1951, in a joint session of the USSR Academy of Medical Sciences and the Board of the All-Union Neurological and Psychiatric Association (a session instigated by Stalin so as to “free Soviet psychiatry of Western influences”), a number of prominent neurologists and psychiatrists were accused of pursuing an “anti-Marxist and reactionary” deviation from the teachings of Pavlov.

The psychiatrist who wrote the subsequent policy report was Andrei Snezhnevsky, who identified a new mental illness: “sluggish schizophrenia.” After Khrushchev’s 1959 speech, the term quickly gained currency and the new illness was frequently diagnosed. Symptoms of the alleged “illness” were such that even the slightest nonconformity of speech or behavior could be taken as a sign of mental derangement. Outspoken dissent might be diagnosed (for example) as indicative of “sluggish schizophrenia with delusions of reform.”

Andrei Vladimirovich Snezhnevsky
Андре́й Влади́мирович Снежне́вский
Snezhnevsky personally signed documents declaring several prominent dissidents legally insane – among them neurophysiologist Vladimir Bukovsky, who would become the first to expose the abuse of psychiatry in the Soviet Union, and spent 12 years in prisons, forced labor camps, and psychiatric hospitals.

Astonishingly, in 1970, one year before Bukovsky managed to smuggle, to the outside world, 150 pages documenting the role of Soviet psychiatry in silencing political dissenters, the American Psychiatric Association named Andrei Snezhnevsky a “distinguished fellow” for his “outstanding contribution to psychiatry and related sciences” at its annual meeting in San Francisco.

In the U.S., we pride ourselves on our supposed freedom of ideological choice and laugh (sadly) at the seemingly absurd willingness of a Soviet medical system to pathologize dissent. And yet, in the U.S., if you dare criticize capitalism or suggest that the U.S. might not be the greatest country in the history of the universe (etc.), you are essentially considered a lunatic, or at the very least imbalanced in some fundamental sense, much the same way Khrushchev considered anyone who questioned Marxist orthodoxy to be psychologically impaired.

We scoff at the idea that dissent is methodically suppressed (even with medication!) in the U.S., and yet the DSM-V spells out, in detail, the very conditions we scoff at. One is called Oppositional Defiant Disorder (yes, ODD indeed). The "disorder," strangely affecting children and adolescents only, constitutes a recurrent pattern of negativistic, defiant, disobedient, and/or hostile behavior toward authority figures that persists for at least 6 months and is not due to a mood or psychotic disorder. To fulfill the diagnosis, an individual must exhibit 4 of the following:
  •     Often loses temper
  •     Often argues with adults
  •     Often actively defies or refuses to comply with adult requests
  •     Often deliberately annoys others
  •     Often blames others for his or her mistakes or poor behavior
  •     Often touchy or easily annoyed
  •     Often angry or resentful
  •     Often spiteful or vindictive
Fortunately for politicians, ODD is not considered to be a disorder of adulthood. Otherwise it would obviously apply to most of Congress.

Up to 60% of ODD patients may go on to be diagnosed with Conduct Disorder, which is like ODD but involves destructive and/or violent behavior (which are not part of ODD). Conduct Disorder, in turn, is considered a precursor of Antisocial Personality Disorder (ASPD), which, strangely, doesn't afflict anyone until age 18. ASPD, meanwhile, is often associated with psychopathy or sociopathy. All of which can be, and often are, in fact, treated with drugs.

What drugs do we use in the U.S. to treat these disorders? Pretty much the same category of drugs the Soviets used: antipsychotics. The only difference is that in today's U.S. we tend to favor "atypical antipsychotics" (which were not available in Soviet days).

Between 1993-1998 and 2005-2009, U.S. doctor’s visits with a prescription of antipsychotic medications increased from 0.24 per 100 persons to 1.83 for children (a 7-fold increase), 0.78 to 3.76 for adolescents, and 3.25 to 6.18 for adults. (See Olfson et al., JAMA Psychiatry, Dec. 2012, or for a somewhat broader discussion see Appendix C in Of Two Minds.) Antipsychotics are largely given to induce compliant, non-disruptive behavior. (One study found that 87.9% of child antipsychotic prescriptions were based on a diagnosis of  “disruptive behavior disorders.”)

Bottom line, we regularly medicate not only children but adults (in the U.S.) with antipsychotics – in fact we do it on an unprecedented scale – to reduce disruption, alleviate agitation, and remediate "disorganized thinking" (one of the signature positive symptoms of "schizophrenia"). The beauty of the American system is that the afflicted, by and large, willingly endorse their own "treatment" (except, of course, for certain children, who may not like the treatment but won't progress through school without it).

The result, in any case, is a compliant/tranquil(ized) populace, a citizenry that doesn't complain about the true sources of its "illness," which might include, say, a conformity-obsessed school system, or a job world that treats "humans" as "capital," or a dysfunctional political apparatus corrupted by corporate influence, or any number of other complaints that might turn out, on close scrutiny, to be quite legitimate.

The Sovietization of the American psychiatric system that began with Andrei Snezhnevsky (who was duly recognized by the American Psychiatric Association in 1970) is now complete, minus the mental hospitals that no longer exist. We allow our "mentally ill" to roam free. It is the land of the free, after all. Is it not, comrade?

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  1. That list of "symptoms" sounds like a normal teenager. It seems to me that we're increasingly considering childhood a social and/or psychological dysfunction. While I don't dispute that ADD & ADHD really do exist, and are hugely debilitating for people with those conditions, I wonder how many 2- and 3-year-olds are being diagnosed with being, basically, a toddler. And now "teenager" is something we have to diagnose and treat. It's time we remembered that children *aren't* adults and shouldn't be expected to think or behave like adults.

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  3. I am a psychiatrist, and a refugee from the former Soviet Union.
    While I agree with you that there are issues with our diagnostic system, I would caution you against making broad generalizations.
    The reason that ODD and Conduct Disorder are diagnosed in younger people, is that we do not want to put a serious label like Anti-Social Personality Disorder on someone so young, and because not everyone will maintain those behaviors into adulthood. These disorders are NOT treated with antipsychotics. They are treated with therapy first, perhaps anti-depressants, and maybe eventually antipsychotics.
    I've also got news for you -- ECT is a very safe and lifesaving treatment. The ECT that we have today is not the ECT of the 60's from One Flew Over the Cookoo's Nest. Please stop perpetuating this dangerous myth that prevents people from getting the treatment that can save their life.
    Also, antipsychotics help people with Bipolar and Schizophrenia maintain stable lives. In particular, people with Bipolar disorder can often function normally, but if they stop their medications (antipsychotics and mood stabilizers) due to "anti-psychiatry" articles like yours, they experience manic episodes and lose relationships, jobs, etc. I know not only patients, but also friends with Bipolar disorder who have experienced this sad cycle.
    Are we prescribing too many anti-psychotics? Probably. There are safer drugs that should be tried first for certain disorders, such as PTSD, in my opinion. However, we should not throw out the baby with the bathwater. And comparing psychiatric care to the Soviet Union's repression is an insult to those who suffered under the regime, such as members of my own family who spent years in Soviet prisons


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