Posted: Monday 8 March 2010
Do you have too much sex? Or not enough? Either way, you’re obviously mentally disordered! Or you very well might be in 2013 when the DSM-5, the new edition of the Diagnostic and Statistical Manual, is published.
Indeed, you may even be classified as mentally disordered if you don’t think about sex as much as you ought to, though the same will happen if you think about it too much too. Of course, the proposed new inclusions in the DSM-5 aren’t all about sex, though you do have to wonder how a psychiatrist will define at what point someone tips over the threshold of having too much or too little sex and at what point, like Goldilocks and her porridge, your sex life becomes ‘just right’?
The most notable feature of the proposed changes is the way in which it widens the scope and lessens the threshold for diagnosis. In real terms, this means that more people will find themselves diagnosed with a mental health problem or personality disorder, pathologised, stigmatised and medicated. Hey, you could even be classified as having a mental health problem if you have Restless Legs Syndrome! You think I’m making this up? I wish I was....
Still not given up smoking? Why, you have Nicotine-Use Disorder, especially if you smoke “larger amounts or over a longer period than was intended.” I wonder how many cigarettes you are supposed to smoke? Perhaps it should start saying on the packet? Talk in your sleep? That’s Rapid Eye Movement Behaviour Disorder!
Got a child who you think might at some point in the future go a bit mad? Get them labelled and drugged now! Although only a small fraction of children at risk of psychosis ever develop it, that hasn’t stopped the working group of the DSM-5 wanting to introduce a Psychosis Risk Syndrome. But maybe your child just has tantrums? No worries, get them diagnosed with Temper Dysregulation Disorder with Dysphoria and they’ll be medicated up in no time. Sorted!
It seems ironic that when the general trend outside of psychiatry is focused on ‘wellness’ and ‘recovery’ in mental health, psychiatry is heading in the opposite direction of wanting to label more and more people with psychiatric diagnoses. This isn’t a new trend of course, with the last edition of the DSM seven times thicker than the first edition, published in 1952.
Unlike other areas of medicine, though, the new conditions are not a result of scientific breakthroughs. How people are diagnosed is essentially a subjective value judgment rather than anything based on scientific evidence. Even so, certain symptoms tend to be grouped together and labels stuck on them. That, however, sounds clearer cut than it actually is, since the same symptoms can be used to diagnose different conditions.
This can be due to a whole number of reasons that have no validity at all. Exhibiting identical symptoms, you’re more likely to be diagnosed as having bipolar if you’re middle class and schizophrenia if you’re working class. You could also be diagnosed with schizoaffective disorder or schizotypal personality disorder. Whatever diagnosis you end up with, the impact on your life, your health and your long-term prospects is going to be very different, in some cases devastating.
It would make sense surely to aim towards drugging and labelling less people rather than more, but sense and psychiatry sometimes make uneasy bedfellows. Once labelled with a mental health condition, you are never cured, the closest you will get is being in remission. Once branded, you are never truly free again. But as more and more people find themselves diagnosed with a mental health problem, perhaps one day it will be so common as to lose all meaning and all the stigma associated with it will disappear with it? I suspect, however, that it will never quite get to that stage.
It does though beg the question of why psychiatry has such an obsession with medicalising, categorising and compartmentalising natural reactions to what has happened to us in our lives and the environment we find ourselves in. To then try to find biological reasons for those perfectly understandable reactions makes no sense at all. If psychiatry were a person, it would be diagnosed as suffering from an obsessive compulsive disorder with delusional tendencies.
Perhaps the most sinister aspect of all this is the underlying pressure to conform. Don’t smoke, don’t misbehave, don’t be unhappy, don’t rebel, don’t make a fuss, don’t have spiritual experiences, and don’t harm yourself unless doing so in a socially acceptable way. Indeed, one of the many proposed alterations to the definition of personality disorder is to specifically mention a lack of cooperativeness as a diagnosable symptom. So, theoretically, disagreeing with your doctor or not taking a medication that isn’t doing you any good could get you diagnosed with a personality disorder.
Rather than creating more and more categories of mental distress and personality disorder, shouldn’t the DSM-5 urge psychiatrists to destroy all previous editions and simply treat people as individuals? Categorization leads to people becoming dehumanised and objectified, forced into little boxes, some labelled as schizophrenic, some as depressive, some as personality disordered, none of them individuals with unique experiences that have produced the people they are today, deeply troubled, distressed and hurting sometimes, but no less human than the psychiatrists who are supposed to be helping them.
Shaun Johnson
Shaun is a Trustee of Mind and has been involved in the service user / survivor movement for many years. He was a member of the NICE Guideline Development Group on Medicines Concordance and has a varied background in writing, publishing, art, music and journalism.
I am quite scared by the future of the DSM and fear that the ICD will only follow.
I have found lately that I've lost all patience for psychiatrists and their labels. When I was first ill, I sought a diagnosis to understand it all, but these days I wonder if it would be better to not label at all
You can present to one psychiatrist a set of symptoms and get one diagnosis and another one and get a completely different diagnosis and half the time it feels like neither is right!
A lack of cooperation is certainly likely to land me with a PD. To be fair, that lack of cooperation and a little suspicion of doctors nearly has already.
Accepting, respecting and loving people unconditionally (as appropriate) are all critically important elements of any relationship and society. What you have documented here is a frightening move away helping, treating and rehabilitating people as individuals, and who are already well to the rear of any queue for social inclusion. Great article, thanks.
Can Mind do anything about this? Shouldn't Mind oppose to such a nonsensical manual? Shouldn't Mind lobby together with other associations and with scientist against this witch-hunting?
Mind might loose their funding if they did that Pierluigi.
There are people who are fighting to get certain labels reclassified right now to offer more social indicators as opposed to biological ones
As far as I can tell, mentalists love having labels. And the more checkboxes you give them, the more labels they can happily apply to themselves.
My girlfriend, for example, doesn't have a dirty habit of picking scabs on her scalp, she has Dermatillomania. The implication being it is a medical condition that she has no control of and therefore no responsibility for.
*rollseyes*
Thank you, Shaun, for writing this:
"Rather than creating more and more categories of mental distress and personality disorder, shouldn’t the DSM-5 urge psychiatrists to destroy all previous editions and simply treat people as individuals? Categorization leads to people becoming dehumanised and objectified, forced into little boxes, some labelled as schizophrenic, some as depressive, some as personality disordered, none of them individuals with unique experiences that have produced the people they are today, deeply troubled, distressed and hurting sometimes, but no less human than the psychiatrists who are supposed to be helping them."
Some psychiatrists are waking up to the problem as well, see the chair of the previous DSM committee Allen Frances below:
It's not too late to save 'normal' -
Psychiatry's latest DSM goes too far in creating new mental disorders.
By Allen Frances
March 1, 2010 Los Angeles Times
As chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994, I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences.
Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.
Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status -- to say nothing of stigma and the individual's sense of personal control and responsibility.
What are some of the most egregious invasions of normality suggested for DSM-V? "Binge eating disorder" is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6% of the population, would qualify.) "Minor neurocognitive disorder" would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be misread as "major depression." "Mixed anxiety depression" is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.
The recklessly expansive suggestions go on and on. "Attention deficit disorder" would become much more prevalent in adults, encouraging the already rampant use of stimulants for performance enhancement. The "psychosis risk syndrome" would use the presence of strange thinking to predict who would later have a full-blown psychotic episode. But the prediction would be wrong at least three or four times for every time it is correct -- and many misidentified teenagers would receive medications that can cause enormous weight gain, diabetes and shortened life expectancy.
A new category for temper problems could wind up capturing kids with normal tantrums. "Autistic spectrum disorder" probably would expand to encompass every eccentricity. Binge drinkers would be labeled addicts and "behavioral addiction" would be recognized. (If we have "pathological gambling," can addiction to the Internet be far behind?)
The sexual disorders section is particularly adventurous. "Hypersexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping.
Defining the elusive line between mental disorder and normality is not simply a scientific question that can be left in the hands of the experts. The scientific literature is usually limited, never easy to generalize to the real world and always subject to differing interpretations.
Experts have an almost universal tendency to expand their own favorite disorders: Not, as alleged, because of conflicts of interest -- for example, to help drug companies, create new customers or increase research funding -- but rather from a genuine desire to avoid missing suitable patients who might benefit. Unfortunately, this therapeutic zeal creates an enormous blind spot to the great risks that come with overdiagnosis and unnecessary treatment.
This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.
Allen Frances is professor emeritus and former chairman of the department of psychiatry at Duke University.
2010, The Los Angeles Times
what a fantastic written article Shaun. Very interesting and informative.
I could find myself in some of those little boxes in different stages of my life despite of so far managed don't get any labels on me.
@Pierluigi While the DSM is influential in the UK, it's actually written by the American Psychiatric Association. Mind works in England and Wales only, and unfortunately we don't have the capacity or remit to lobby a group based in the US.
@Mindreader, financial independence is very important to Mind. We have a broad base of supporters (the general public, trusts and companies - but never pharmaceutical companies), which allows us to speak up without fear of losing funding.
Wow, what an interesting and thought provoking article and set of comments. I find it really amazing that every act of human behaviour has to be categorised, labelled and sub-labelled so that everyone knows their place and how they should be. But of course, it isn't really as simple as that and by making a label for everything, we risk creating discrimination for some and exclusion for others.
Of course, having a label can be helpful in terms of seeking treatment for behaviours which can be quite negative to the individual.
Trem comments "As far as I can tell, mentalists love having labels. And the more checkboxes you give them, the more labels they can happily apply to themselves.
My girlfriend, for example, doesn't have a dirty habit of picking scabs on her scalp, she has Dermatillomania. The implication being it is a medical condition that she has no control of and therefore no responsibility for."
Until I read that, I had no idea that there was a proper name for something I have been doing for 15 years now. It was only really in the last couple of years that I even understood that it was a form of compulsive self-harming behaviour. I am not going to happily apply this label to myself, but I am going to use it to try and get some assistance from my GP to attempt to break the habit.
I don't accept that having a label removes the responsibility from people. I think it can be something we can build on to help ourselves learn to cope better with things and handle difficult situations in more productive ways. However, I do find it extremely concerning that every type of human behaviour is now being marked up and classed as a disorder. Worrying about things is not abnormal or the sign of a disorder, thinking about sex is fine, scratching your skin is also not abnormal or the sign of mental illness. It is only when these behaviours are taking over and affecting your ability to function or having a negative impact on your existence that they become a problem and what is normal for one person may not be for someone else.
The continuing growth of the lists of disorders is really making more and more people feel that they may not be 'right in the head', rather than increasing an awareness of our different and valuable approaches to life. Perhaps the people making up these new definitions should apply one to themselves; "negative categorisation disorder"!
And if anyone else, like me, experiences dermatillomania, perhaps you might find the following useful:
As someone who has experienced mental health problems, but also now works in an Early Intervention in Psychosis team, I welcome the new Risk Psychosis Syndrome. I really do believe it will put some extra weight behind the Early Intervention movement, and allow us to continue to get people better faster, or prevent a full psychotic episode at all.
Eve@Mind, anyone can lobby the DSM committees irrespective of geography, there are psychiatrists, service users and groups in the UK who are doing so now. Everyone knows Mind doesn't receive pharmaceutical funding that was not my inference. Mind cannot go too far against DH policy [and all health and social policy works on the basis of diagnosis as described by DSM/ICD] because to do so would mean risking any funding received by the DH [if any comes from there] or at least it would risk political good will
Excellent and really interesting post - thank you Shaun.
Taking things to their logical conclusion, with more and more 'conditions' added every few years, it is reasonable to expect (as you mention) everyone to be classed as having a mental health disorder at some time in the future!
That or alternatively, the only individuals considered 'normal' will be boring, middle of the road, lukewarm individuals. Thinking again though - bet there would eventually be a disorder for these individuals as well. They would be abnormal because they are normal.
If it wasn't so worrying it would be highly amusing! As it is, it just horrifies me.
Dear Shaun
Thank you so much for this post.
From personal experience I can say that the mental health professions are out of control with regard to classifying everyday behaviour as "abnormal".
Whilst acknowledging there is valuable work done in mental health care, my own view is that there is also a parasitic element in mental health care provision which generates issues from nothing to feed a significant and growing industry based on drugs with questionable credentials and "professionals" with limited and unmeasurable effectiveness. The professional bodies and pharmaceutical companies seek to promote and elevate the status and power of their "industry" above the well being of the public.
To my mind this is no different than any other scam such as dodgy damproofing or pyramid sales, with the critical exception that proving malpractice is so much harder. The points you make in your last two paragraphs are truly frightening and should be a wake up call for every decent health practitioner to stand up and be counted.
With best wishes for alerting people to this corrosive and sinister aspect of "mental health services".
I think this thread, and quoted sources, is/are in danger of undoing the work Mind does looking at the status of mental illness in society. Should we be de-normalising mental illness. Hello, do you think that the '1 in 4' statistic Mind uses to fight stereotypes and discrimination is bogus? I have picked up the view from various other sources that mental illness is based in normal states of mind/behaviours that become exxagerated (by various factors)- there is a fuzzy spectrum, imagine the concept/category (as aside from disputing the terminolgy) describing different facets of people over time. Labels only become dangerous when they treated by some as an excuse to de-individualise, to treat on automatic pilot(to swallow something within the use-by that is clearly fishy). Or otherwise be damagingly crude. It is those over-medicating or otherwise damaging who are the people we should sort out and lobby. (Perhaps through professional bodies' conintuing development programmes.) Maybe the Manual's diagnoses, they are not labels they are better described as handles for use in the description of our foibles,as they are colloquially, and the best path forward is accepting that feature of language in order to marry it with robust definitions of social, cognitive and medical models and, importantly, scales. We need to have a sense of ourselves as peers with each other and to I think I feel some empathy with every viewpoint here but maybe that is my approval-seeking schema! I get frustrated in psychotherapy (schema/cbt) that my thoughts are being re-interpreted in terms of models - and a therapist who avoids my attempts to ponder whether I have full-blown OCD/Bipolar/BPD/shizothymic tendancies and whether there are actually some points of effective agreement between theoretical approaches to therapy. Everyone should have a common language with which to deal with their head. And gut. And so on.
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