Last week, at my mom’s house in New Jersey, I was thumbing through her copy of the Sunday New York Times, when an article titled “Idea of New Attention Disorder Spurs Research, and Debate” caught my eye. “Called sluggish cognitive tempo,” the author writes in the second paragraph, “the condition is said to be characterized by lethargy, daydreaming, and slow mental processing.” Approximately two million children are thought to have the disorder.
Sluggish cognitive tempo??? I thought to myself, rolling my eyes as I read that sentence. I have that on a GOOD day. A search on PsycINFO, the most comprehensive database in the field of psychology, turned up 76 articles about sluggish cognitive tempo (SCT). One of those articles, written by Stephen Becker of Miami University, identifies two subtypes of SCT – daydreamy-spacey and sluggish-lethargic. (I swear to you I’m not making these terms up.) There’s even a Sluggish Cognitive Tempo assessment scale, which is a checklist that includes items such as the following:
Appears to be sluggish.
Seems to be in a world of his or her own.
Is underactive, slow-moving, or lacks energy.
Not to belittle the experience of people who really struggle with being unmotivated, sluggish, and mentally distracted, but it’s times like these when I feel like I need to apologize on behalf of my professional field. I wouldn’t be surprised if some children exhibit “sluggish cognitive tempo” in school because they’re bored, or because they’re not given enough opportunities for physical activity, or because they don’t get adequate nutrition, or because their sleep is disrupted. Interestingly, all of the professionals quoted in the New York Times article were affiliated in some way with pharmaceutical companies (which made me question the journalistic objectivity of the article).
The mental health field has been under intense scrutiny for decades, especially since the publication of DSM-5. This recent revision of the diagnostic manual has been openly and venomously criticized by Robert Spitzer (who chaired the DSM-III revision), Allen Francis (who chaired the DSM-IV revision), and Thomas Insel (who is the director of the National Institute of Mental Health) for its lack of scientific rigor. Psychology as a discipline has a long and checkered history of overpathologizing and wrongly pathologizing people – particularly when it involves using diagnosis to police non-normative behavior.
As you can probably guess, I’m a little jaded when it comes to the introduction of new psychiatric labels. And I’ll cite some historical examples of the harmful and grossly negligent use of diagnosis to explain why. In the mid-1800s, psychiatrist Samuel Cartwright (who, ironically, was mentored by the mental health reformer Dr. Benjamin Rush) wrote a book titled Diseases and Peculiarities of the Negro Race. In this book, he identifies two “mental disorders” involving Black slaves. If a slave didn’t work hard, or was perceived to be lazy, he or she might be diagnosed with dysaethesia aethiopica. If, however, a slave tried to run away (or even express a desire to flee), he or she could be diagnosed with drapetomania. Both of these disorders, according to Cartwright, had their roots in the Bible – if a slave were truly following God’s will, his reasoning went, then that slave would work hard, be obedient to his or her master, and have no desire whatsoever to run away. These diagnoses functioned, in essence, as a way to police behavior among marginalized people.
I can give you another example. Take the homosexuality diagnosis, which was listed in the 1952 edition of the DSM as a “sociopathic personality disturbance.” After a series of protests by gay rights activists, the homosexuality diagnosis was ultimately removed from the DSM in 1973. However, what appeared in its place was a diagnosis called ego-dystonic homosexuality, which means that being gay causes you “clinically significant distress.” (As an aside, I think a lot of LGBTQ people, even today in 2014, experience “clinically significant distress” when first realizing their identity.) In 1987, the American Psychological Association passed a resolution opposing the use of the DSM-III diagnosis of ego-dystonic homosexuality and the ICD-9 diagnosis of homosexuality (which still existed at the time). The DSM eventually dropped the ego-dystonic homosexuality diagnosis, and while the ICD-10 no longer includes homosexuality as a diagnosis, a person can still be diagnosed with ego-dystonic homosexuality under that taxonomy.
I wish I could say all of this is ancient history, but unfortunately it’s not. In DSM-III-R, when the diagnosis of ego-dystonic homosexuality was removed, a new diagnosis called gender identity disorder found its way in. The diagnostic criteria for this disorder included, according to the DSM:
A strong and persistent cross-gender identification;
Persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex;
Marked preoccupation with cross-gender activities.
DSM-5, interestingly, no longer contains the gender identity disorder diagnosis – largely because of the efforts of transgender activists and their allies. However, a new diagnosis – gender dysphoria – quietly snuck in. Although there are a few technical differences between gender identity disorder and gender dysphoria (including the fact that intersex people are now included under the gender dysphoria criteria, much to the chagrin of many intersex activists), there’s one major difference, which is summed up in a memo issued by the American Psychiatric Association: “It is important to note that gender nonconformity is not in and of itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition” (emphasis added). Clinically significant distress. Sound familiar? Certainly sounds like history repeating itself to me.
Let’s recap. Homosexuality was a disorder. Then it was replaced with ego-dystonic homosexuality. Then ego-dystonic homosexuality wasn’t a disorder, but it was replaced with gender identity disorder. Then gender identity disorder wasn’t a disorder, but it was replaced with gender dysphoria. The next thing we know, the inattentive form of attention deficit hyperactivity disorder will be eliminated, but it will be replaced with – you guessed it – sluggish cognitive tempo, daydreamy-spacey subtype.
I firmly believe in the positive power of diagnosis. If you are struggling with a strange collection of psychological symptoms, identifying a syndrome that involves those symptoms can be incredibly validating (oh wow! This thing I have actually has a name!), and potentially indicate what treatments might help. However, once a person received a diagnosis – especially one that’s stigmatizing – it has the potential to stick with them throughout their lives (read David Rosenhan’s classic article “On Being Sane in Insane Places” for some perspective on this). Moreover, if a person is being diagnosed solely because they don’t conform, and if society’s reaction to that nonconformity is causing “clinically significant distress,” we need to reconsider whether the diagnostic label empowers the person, or if it oppresses them even further.