Is nobody bog-standard, run-of-the-mill normal anymore? Are we all – by dint of a massive expansion of diagnostic categories – mentally ill? Such are the questions now being posed by a number of experts following the release of the preliminary draft revisions to the current diagnostic criteria contained in the so-called bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders. For the lexically-phobic amongst you, that’s DSM for short.
There is little doubt that over the past 20 or so years, the sheer number of mental illnesses and disorders has proliferated. Aspects of our behaviour, once so colloquially familiar, have acquired technical, medical-sounding appellations. Shyness has become ‘avoidant personality disorder’; anger has been reclassified as ‘intermittent explosive disorder’. The list unfurls itself into absurdity. Little wonder that one in four Americans can now be said to suffer from a mental illness.
The DSM, as the namer and shamer of mundane behaviours, seemingly now stands at the vanguard of the medicalisation of everyday life. The first edition of the American Psychiatric Association’s DSM was published in 1952. That particular version contained a then unprecedented 60 diagnoses of mental illness. Over the next 40-odd years it expanded its reach ever further into our most routine of mental states, finding a diagnosis where before there was, for example, just a bashful man or woman. By 1994, the fourth edition of the DSM recognised a total of 384 mental ailments (plus 28 ‘floating diagnoses’).
If the preliminary draft revisions are any indication, the fifth edition of the DSM, to be published in May 2013, looks set to continue this trend. This time, however, there seems to be something of a reaction against the process of turning unremarkable behaviours into diagnostic categories, as captured in a critical new edition of the Journal of Mental Health. As Til Wykes of the Institute of Psychiatry at King’s College London argues, the DSM is ‘leaking into normality. It is shrinking the pool of what is normal to a puddle.’ In particular, the proposed ‘at risk’ (of psychosis, dementia, etc) category has been singled out for special criticism – which is hardly surprising given that it means you only need to be showing the potential for a mental illness to be diagnosed as possessing one. As Robert Spitzer, a professor of psychiatry at Columbia University, pointed out in February: ‘There will be adolescents who are a little odd and have funny ideas, and this will label them as pre-psychotic.’
Spitzer’s concerns were echoed this week by Dr Felicity Callard of the UK’s Biomedical Research Centre for Mental Health: ‘If this category were to be introduced the people likely to be given this diagnosis are going to be relatively young. What are the implications of someone receiving a diagnosis that is not a diagnosis of a disorder as such, but a potential disorder?’
At first glance, these concerns seem valid. The expansion of psychiatric diagnoses into the pre-illness phase opens up a worryingly vast area for clinical intervention. And the reclassification of the previously quotidian does indeed look set to ‘shrink the pool of what is normal to a puddle’. For example, in the future you could be said to be suffering from ‘anxious distress’ if you show two of the following symptoms: ‘irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen.’ A touch of first-date nerves? No, you’re now suffering from anxious distress.
More absurd still is the possible inclusion of a ‘hoarding disorder’ – that is, a ‘persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions’. If you’re wondering whether you’re afflicted with said condition just have a look around you: ‘The symptoms result in the accumulation of a large number of possessions that fill up and clutter active living areas of the home or workplace to the extent that their intended use is no longer possible.’ It’s a wonder soap-dodging isn’t up for inclusion: ‘Symptoms will result in a large accumulation of flies and, in inverse proportion, the disaccumulation of friends and associates.’
The ease with which one can now be flippant about mental illness indicates part of the problem. Serious psychiatric conditions now sit alongside the trivial and banal. Despite claims to the contrary, the expansion of psychiatric diagnoses is not a mark of scientific, medical advance – it is the sign of the devaluation of mental illness. The distinction between the well and the ill has crumbled. In its place stands a populace indiscriminately in need of a therapist.
But what is strange about this current uprising against the tyranny of psychiatry is the extent to which all criticism seems to be focused on the DSM itself. It is as if this volume, by the sheer force of its descriptive and classificatory contents, is somehow held responsible for the tendency now to treat commonplace emotional states as mental disorders. But is a book really that powerful? Can its words, its authors’ utterances, really be that magical? That is the problem with the current attack on the DSM. Just as more literal-minded Christians believe that ‘in the beginning was the word’, so the DSM’s critics invest the bible of psychiatry with a similar enunciatory power: they name it, and so it is. As a consequence, the real evolution of what Frank Furedi has called ‘therapy culture’ is overlooked. Instead all eyes turn to the DSM, as if its contents, by their magical force alone, create the terms of the world in which we live.
By attributing so much significance to the DSM, the social reality of the need for a therapeutic intervention is effaced. This is to get the relationship between us as members of society and an ever-growing retinue of counsellors the wrong way round. The medicalisation of everyday moods and behaviours is not a DSM-created illusion, a money-making scam by classification-happy psychiatrists. Rather, this process of rendering our most mundane behaviours up for an external, therapeutic intervention is born of the atomisation of the social world. In this sense, the therapeutic state is not a trick or a DSM-inspired error: it expresses a civil society in which the individual is genuinely isolated.
Traditional support networks of family and local community have disintegrated. And collective institutions such as trade unions, political parties or the church have withered. The consequences are real. An individual might have once forged his existence and tackled the problems thrown up by life in terms of those collectivities - indeed, these institutions often provided the foundations for a sense of agency, the sense that the social world was something to be influenced, changed even, not suffered. Without these collective institutions to mediate an individual’s existence and struggles, his life becomes one less of striving than of mere survival. And it is upon society as an agglomeration of isolated, vulnerable individuals that the therapeutic state takes root.
A comment by Nick Craddock, professor of psychiatry at Cardiff University, in defence of the DSM, is telling in this regard: ‘Diagnosing bipolar disorder, for example, can be very helpful. It can transform people’s lives, make them feel accepted and can give their symptoms meaning.’ In other words, the diagnosis of a disorder does more than simply indicate a course of treatment; it gives meaning and it makes one feel accepted. Where once an individual might have defined and affirmed themselves in terms of a project external to them, whether as part of a church or political party, left to our own limited devices, we are expected to define and affirm ourselves in terms of our inner life - our feelings and emotions. This is why the diagnostic categories have expanded to encompass the most mundane of emotional states: as a mechanism of social mediation, a means of overcoming atomisation, the categories of mental disorder must cater for everyone. This, of course, does nothing to alter an individual’s existence; it merely reconciles him to it.
The expanding categorisation of the DSM is not a positive phenomenon by any means. But by attacking the symptom of a social malaise, critics miss the deeply rooted, social cause.
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