Is that really a disease? Epistemology and crank-ism

And out of the ground the LORD God formed every beast of the field, and every fowl of the air; and brought them unto the man to see what he would call them; and whatsoever the man would call every living creature, that was to be the name thereof. (Genesis 2:19)

Human beings are great organizers. As far back as written history goes, people have named and classified what they observe. In fact, it forms the basis for modern science. Linnaean classification, based on observation of traits, predates modern cladistic and genomic classification of organisms, based on arguably more fundamental characteristics.

The same is true of human disease. Hippocrates was a great observer of human disease and correctly described many conditions in ways easily recognizable to modern doctors. Today, where we know causes of disease, classification has become more precise. For example, we may divide diseases into those caused by bacteria, viruses, genetic defects, etc. When we don’t know the cause of a disease, we still rely on observation. We have various syndromes such as lupus where we do not know the cause, and must fall back on description. This is especially true of psychiatric diseases, where causes are largely unknown, but identifiable patterns of thought and behavior exist.

It is of course most desirable to be able to describe a disease and know its cause, but being able to name less “concrete” disorders is also helpful. It allows researchers to identify cases and test interventions. Even though lupus does not have one easily identifiable cause, we can describe it well enough to study treatments, thereby helping design treatments.

This all leads up to a larger epistemologic question: what is a disease?

I bring this up because I got spammed by my favorite internet doc, Joseph Mercola. The email contained an article from his website written by some other crank. In the title, he asks, “How many of these ridiculous ‘disorders’ do you suffer from?” The premise is a familiar one, dealing in a rather unsophisticated way with the issue of “medicalization” of “normal” states. This is a “real” issue, and is discussed often in such areas as Attention Deficit/Hyperactivity Disorder in children, especially in relation to treating kids with medication.

To decide what is “disease” we also have to know what is “normal”, as disease can reasonably be defined as “a significant deviation from normal that causes discomfort, shortens life, or both.” A blue mood causes discomfort. But how “blue” do you have to be before it is significantly abnormal? Operational definitions have been developed to deal with this problem. There is inherent arbitrariness in this process. What is it about two weeks of severely depressed mood that is different from one week or three weeks? For diseases where the underlying physical mechanism is unclear, rational consensus is usually reached by experts.

So where does the crankery come in? Right about here. Cranks, denialists, and conspiracy theorists shove the crowbar of ignorance into the interstices of our medical knowledge. Into this artificially widened gap, they place their paranoid ideas. This crank follows the usual pattern of decrying “big Pharma” but does it particularly poorly:

Do you have difficulty sleeping after drinking coffee? The problem isn’t a product of your poor judgment in guzzling java immediately before retiring. You are a victim of 292.89 — Caffeine-Induced Sleep Disorder F15.8. If you reflect on your shyness while tossing and turning, the problem could be the epidemic of 300.23 — Social Phobia F40.1. Don’t worry. Drug treatment is available.

What a “friggiot”1. When teaching about and evaluating sleep disorders, for instance, it is helpful to have a framework on which to set the relevant knowledge. For sleep one could divide disorders into medication-induced, circadian rhythm disturbances, mood disorders, improper sleep hygiene, sleep-related breathing disorders, sleep-related movement disorders, etc. If you don’t have framework such as this (and I made it up—this one isn’t from “the book”) then you have no way of organizing, communicating, and using knowledge. When a patient complains of sleep problems, he doesn’t usually say, “I can’t sleep well because I drink coffee at bedtime.” He usually says he can’t sleep well, and the doctor, using her knowledge of sleep disorders, asks questions and examines the patient, formulates a hypothesis, and tests it. It’s called science.

I won’t bother going through the rest of his article, because the same reasoning applies. More ignorance is rarely the answer to a problem. One of the great successes of human intelligence is the ability to describe and name. Even the authors of the Bible knew this well enough to include it “in the beginning”.


1Friggin’ idiot


  1. Speaking of cranks, your context-based ad bar is urging my to buy the ‘Rite at Home Healthcate Magnetic Matress Overlay Twin’ :> Along with some suspicious-looking books.

  2. KHANNNN!!!!!

  3. Colugo

    Listen, I loathe New Age freak-os who rant against Big Pharma and so-called “allopathic” medicine as much as you guys.

    But to be fair, there is such a thing as socially constructed categories of illness and bogus causes, especially when it comes to psychiatry. Remember homosexuality-as-illness? Hysteria? Migraines and asthma as psychosomatic? Autism due to “refrigerator mothers”? The lobotomy craze? Fashionable diagnoses are nothing new. How much of the surge of Asperger’s diagnoses is real?

    Outside of the psychiatric realm, how about the diagnosis of slipped organs in the early X-ray era, due to organ locations being known from cadavers and surgery – when the subject is supine – rather than standing, like during an X-ray examination. There were quite a few unnecessary surgeries until gravity was identified as the culprit.

    Or consider the bowel-obsessed era of the early 20th century, in which overchewing food, colonics, and bowel reduction surgeries were the rage. The latter were advocated and supplied by prestigious MDs.

    Scientific method, scientific shmethod. Sure, it can put the breaks on a biomedical Dutch tulip. But it’s not the only thing driving cycles of diagnoses. The fact is that a lot of M.D.s are just glorified technicians following cookbooks or medico-ideologues rather than scientists or detectives.

  4. Interesting, but tangential. As we understand disease and treatment better, our diagnoses become more refined. Cystic Fibrosis is now defined both clinically and genetically, for example.

    You can come up with lots of examples, especially if you go back far enough, of diseases that didn’t pan out (although Hipporates did a damn good job of defining diseases well).

    Evidence-based medicine has revolutionized how we diagnose and treat disease. I suspect that there are few examples (exceptions, really) in modern medicine of “crank” illnesses subscribed to by real doctors.

  5. bob koepp

    Well, inappropriate medicalization _is_ a problem. And pharmaceutical companies have lately gotten into the business of identifying “new diseases” for which they just happen to have “cures” waiting on the shelf. How convenient…

    I think I’ll stick with the pathologist’s notion that a disease (more properly, a pathological condition) is a dysfunctional condition; i.e., an impairment of natural functional capacity. To delineate natural functional capacities, I think we can do no better than appeal to evolutionary theory, and construe functions as adaptations; i.e., capacities that that have been “selected for” in an evolutionary time frame.

  6. More than creating new diseases is the hyping of old ones. Restless leg syndrome certainly exists, but probably not as much as the makers of all these new drugs would like you to think.

  7. Somewhat off topic.

    Your comment about ADHD was ambivalent.

    The premise is a familiar one, dealing in a rather unsophisticated way with the issue of “medicalization” of “normal” states. This is a “real” issue, and is discussed often in such areas as Attention Deficit/Hyperactivity Disorder in children, especially in relation to treating kids with medication.

    Are you arguing that ADHD is not a real condition, but the medicalization of normal behavior? In one sense, Steven Hinshaw agrees with you. Answering the question, Why do some psychologists claim that ADHD doesn’t exist as a syndrome?” Hinshaw says:

    “I believe that there are both good and bad reasons for this claim. The behaviors that comprise ADHD (inattention, impulsivity, hyperactivity) are indeed part of normal development, so it is a real and valid question to wonder where the diagnostic cutoff should be. Also, the recent publicity about the rise in diagnosis and treatment makes many suspicious of ‘over-medicalization’.

    “On the other hand, the same issues, such as the normal distribution of constituent symptoms, and the difficulty of ascertaining cutoff points, pertain to many overtly “medical” conditions (for example, hypertension). Yet many people tend to see behavior as completely under one’s volitional control. I believe that misinformation and the tendency to stigmatize persons with behavior disorders are the real culprits.”

    Later in the same interview:

    “Perhaps one of the most shocking findings, says Hinshaw, has been that children with ADHD are the most disliked group of youngsters in any crowd—more so than children with depression, autism, or delinquent problems. Hinshaw explained to a group at last year’s BrainConnection to Education spring conference that research has shown that peer rejection is the best predictor in young children of later problems in school, including dropout and mental health problems.”

    It seems that ADHD is overdiagnosed in some areas of the country, and underdiagnosed in others.

    Froelich et al. (Arch Pediatr Adolesc Med. 2007;161(9):857-864 ) Conclusions: Of US children aged 8 to 15 years, 8.7%, an estimated 2.4 million, meet DSM-IV criteria for ADHD. Less than half of children meeting DSM-IV criteria report receiving either a diagnosis of ADHD or regular medication treatment. Poor children are most likely to meet criteria for ADHD yet are least likely to receive consistent pharmacotherapy.

    David Rabiner has some excellent resources for parents and clinicians. His discussion of the recently-completed Multimodal Treatment Study of Children with ADHD (MTA) is particularly clear. The MTA study found that for many children, a combination of behavior management training (for parents and for the child) plus very closely controlled medication made the biggest improvement.

    There is no one correct way to treat ADHD.

    Other authoritative sources of information:
    NIMH on ADHD. Includes discussion of medication issues. Medline Plus on ADHD, also discusses medication National Resource Center on ADHD, a lay site sponsored by the largest national organization, CHADD.

  8. ~In my best whispering voice…

    Pssst… Hey Pal, epistemology in your title is missing an “O”.

  9. bob koepp

    pssst… since attention has been diverted in a particular direction, the epistemological question would be “How do we know which conditions are diseases?” The question “What is a disease?” is a piece of medical ontology. Just sayin.

  10. Ontology and epistemology can be very similar concepts for the non-philosophers like myself. In this case there is a question of knowledge and a question of “what is…”, so I took an intellectual short cut and used a big word. Feel free to tear it apart at will.

  11. bob koepp

    No need to tear any thing apart. A simple formula I got from my first philosophy teacher was:
    Ontology is about what there is.
    Epistemology is about how we know what there is.

  12. I certainly believe/know that ADHD is a very real and fairly common disease…but there is a legitimate discussion to be had regarding diagnosis frequency, etc. Unfortunately it’s a discussion that attracts a lot of cranks.

    Sometimes the cranks get in there hard, but often the discussion is productive.

  13. It’s funny, before I wrote this piece a while back, I thought about whether to use ontology or epistemology and i can’t remember how I decided…there may have been a quarter flipped…and beer.

    One thing I like about blogging (besides having my horible speling fixed) is the back and forth of learning that you can’t get from regular writing.

  14. To Bob Koepp,

    Bob, if there ever was a field that Gettier’s theory of justified true belief applies, it would have to be medicine. So, to define epistemology as how we “know” what there is would be a misnomer as well. In this instance, it would have to be how we come to believe what is believed, wouldn’t it?

    Now my head hurts. I need another beer…

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