More on health issues from The Atlantic Monthly.

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Interviews: "The Pursuit of Happiness" (August 5, 2003)
Carl Elliott, the author of Better Than Well, talks about amputee wannabes, Extreme Makeover, and the meta-ethics of bioethics.

Flashbacks: "Should We Outlaw Smoking?" (August 1995)
Articles dating back to 1860 rhapsodize about the joys of smoking, lament the difficulties of quitting, point to the correlation between smoking and lung cancer, and explain why we smoke in the first place.

Getting Normal

August 13, 2003
merica is addicted to drugs. We take caffeine to perk up, nicotine to calm down, Prozac to cheer up, and Ritalin to buckle down. Many millions of people across the country take prescribed psychotropic drugs—substances that alter behavior, emotion, or perception—and countless more find other ways to get a quick fix. It is only a matter of time before the next wonder drug pathologizing our bad moods and promising to fix us up hits the market.

A number of new books document our growing dependence on drugs. Prozac on the Couch, published in June, and Better Than Prozac, published in July, echo Franz Kafka's observation that "writing prescriptions is easy, but understanding people is hard." And Better Than Well, published in March, and The Pursuit of Perfection, to be published this fall, explore the phenomenon of using drugs and other medical methods to alter and improve oneself. Elizabeth Wurtzel's 1997 bestseller Prozac Nation will be released as a film later this year.

Though the quest for self-improvement through drugs has become more sophisticated in recent years, it is by no means new. Indeed, the use of tobacco as a mood-regulator was documented in The Atlantic as early as August 1860. In "Tobacco," David William Cheever examined nicotine's chemical components and described its effects, negating charges of their deleteriousness.

Cheever explained that from the time English adventurers imported the tobacco habit from the Americas, political and religious officials throughout Europe rebuked the practice and the "extravagance it occasioned." But while its use was controversial, its popularity was uncontested. "Tobacco, according to some authorities," Cheever wrote, "holds the next place to salt, as the article most universally and largely used by man,—we mean, of course, apart from cereals and meats." He speculated that tobacco "must meet some instinctive craving of the human being," and suggested that its popularity derived from the variety of beneficial effects it was thought to have.
All classes, all ages, in all climates, and in some countries both sexes, use tobacco to dispel heat, to resist cold, to soothe to reverie, or to arouse the brain, according to their national habitations, peculiarities, or habits....

It relieves the little vexations and cares of life, soothes the harassed mind, and promotes quiet reflection. This it does most of all when used sparingly and after labor. But if incessantly consumed, it keeps up a constant, but mild cerebral exhilaration. The mind acts more promptly and more continuously under its use. We think any tobacco-consumer will bear us out in this definition of its varying effects. After a full meal, if it does not help, it at least hides digestion. "It settles one's dinner," as the saying is, and gives that feeling of quiet, luxurious bien-aise which would probably exist naturally in a state of primeval health.
More than a century later, despite copious evidence that smoking caused cancer and other health problems, people were still finding reasons to smoke. In "Addicted to 'Getting Normal'" (October 1991), Kathleen Cushman reviewed David Krogh's Smoking: The Artificial Passion, which she described as a "clearheaded exploration of who smokes and why." According to Krogh's book, Cushman explained, people smoke because they "can so subtly and precisely regulate their moods with nicotine."
People use "workplace drugs" like tobacco, Valium, and caffeine ... not so much to induce an exotic sensation as to deal with the stresses and strains that make us less ourselves—not to get high, that is, but to "get normal." What is particularly startling about nicotine is its ability to moderate states of mind and body on both ends of the scale: it relaxes you if you're tense, mildly stimulates you if you're below par.
To explain tobacco's popularity in spite of its obvious drawbacks, Cushman pointed to its ability to heighten concentration and provide relief from a variety of unpleasant states.
One of the most appealing qualities of this substance—an acrid weed, after all, whose taste and harshness tobacco companies spend millions to disguise—is that it appears to enhance one's ability to concentrate and to process information over a prolonged period. Among those who sit at a typewriter hour after hour—as among factory workers and truck drivers and data processors—nicotine actually seems to improve job performance, returning them to normal from states as various as boredom, depression, anxiety, and stress.
Of course, nicotine is just one of many options for those who seek to, as Cushman put it, "get normal." In "White-Collar Pill Party" (August 1966), Bruce Jackson reported on a growing trend of well-educated, middle-class professionals taking psychotropic commercial drugs in order to help them conform with societal norms and expectations. "They take drugs," he wrote, "to avoid deviance—so they can be fashionably slim, or bright and alert and functional, or so they can muster the quoi que with which to face the tedium of housework or some other dull job." Such drugs, he conceded, could sometimes be helpful.
There is nothing wrong with using chemicals to help cope with life. That is one of the things science is supposed to do, help us cope, and the business of living can be rough at times. And we have the requisite faith: I am sure that far more Americans believe in the efficacy of a pill than believe in God.
The problem, he argued, was that drugs (and their alluring advertising) were increasingly becoming a worrisomely dominant "part of the American way of life."
A lot of people take a lot more pills than they have any reason to. They think in terms of pills. And so do their physicians: you fix a fat man by giving him a diet pill, you fix a chronic insomniac by giving him a sleeping pill. But these conditions are frequently merely symptoms of far more complicated disorders. The convenient prescription blank solves the problem of finding out what the trouble really is—it makes the symptom seem to go away.
Given our readiness to dose ourselves to perfection, it should not come as a surprise that we have also demonstrated a willingness to medicate our children. In 1961, Ritalin, a drug mainly prescribed for Attention-Deficit Hyperactivity Disorder (ADHD), was approved for use in children. Since the mid-eighties its use has skyrocketed. In "Suffer the Restless Children" (November 1989), Alfie Kohn, a human behavior and education theorist, argued that ADHD was a dubious diagnosis, and that Ritalin was too readily prescribed.

Guidelines for the diagnosis of ADHD, Kohn explained, rely on an arbitrary rating scale that "gives the appearance of scientific precision" but in truth represents only a collection of "subjective judgments about whether a child bounces around too much." Such alleged symptoms as "restlessness, impulsiveness, and difficulty paying attention," he pointed out, can also result from "poor nutrition or too little sleep." But so eager are many physicians to identify and treat the disorder that in some cases, when parents, teachers, and pediatricians do not all agree that a child shows symptoms of ADHD, "specialists have responded by fashioning a subcategory of the disorder called 'situational hyperactivity.'" The adults in the child's life, Kohn suggested, tend to welcome Ritalin treatment, in part because it makes their own lives easier, since, for example, "parents' reliance on commands and punishments drops significantly when their hyperactive children are put on medication."
Besides being less distractible and better able to sustain attention, the medicated child typically becomes less aggressive and less apt to get into trouble, less obnoxious to his peers, easier for his teachers to handle, and generally more compliant. Unsurprisingly, parents and teachers are often pleased with the change they see in a child who is put on Ritalin.
But should a child be medicated, Kohn wondered, to "reduce fidgeting"? The carelessness with which ADHD is diagnosed and treated, Kohn wrote, "may provoke larger, more disturbing questions about the theory and practice of mental health in the United States."

—Sara Lipka

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Sara Lipka is on the editorial staff at The Chronicle of Higher Education. She was recently a new media intern for The Atlantic.
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