PSYCHIATRIC researchers recently estimated that half of the American
population has had or will have a mental disorder at some time in their
life. A generation ago, by contrast, only a small percentage of the American
population was considered mentally ill. Are we all going mad?
Freud started this. He made us suspicious that any behavior was potentially
rife with psychopathology. As a neurologist, he used the medical language of
pathology to suggest that the demands of civilization on our fragile human
nature were such as to make all of us somewhat neurotic.
The current psychiatric bible published by the American Psychiatric Assn.,
"The Diagnostic and Statistical Manual of Mental Disorders," or
the DSM, continues this tradition of making us all crazy.
Because there are no biological tests, markers or known causes for most
mental illnesses, who is counted as ill depends almost entirely on
frequently changing checklists of behaviors that the DSM considers as
symptoms of mental disorder. In the recent research, lay interviewers asked
a sample of people to respond to lengthy questionnaires based on the DSM
lists. Computer programs then counted the responses to determine if those
interviewed had ever had the required number of behaviors for any mental
disorder at some time in their life.
We keep getting higher estimates of mental disorders in part because the APA
keeps adding new disorders and more behaviors to the manual.
Since 1979, for example, some of the new disorders and categories that have
been added include panic disorder, generalized anxiety disorder,
post-traumatic stress disorder, social phobia, borderline personality
disorder, gender identity disorder, tobacco dependence disorder, eating
disorders, conduct disorder, oppositional defiant disorder, identity
disorder, acute stress disorder, sleep disorders, nightmare disorder,
rumination disorder, inhibited sexual desire disorders, premature
ejaculation disorder, male erectile disorder and female sexual arousal
disorder. If you don't see yourself on that list, don't fret, more are in
the works for the next edition of the DSM.
Because so little is known about the causes of most mental disorders, just
about any behavior can look like a symptom. Here is a selection from
hundreds of behaviors listed in the DSM, behaviors that signify one disorder
or another: restlessness, irritability, sleeping too much or too little,
eating too much or too little, difficulty concentrating, fear of social
situations, feeling morose, indecisiveness, impulsivity, self-dramatization,
being inappropriately sexually seductive or provocative, requiring excessive
admiration, having a sense of entitlement, lacking empathy, fear of being
criticized in public, feeling personally inept, fear of rejection or
disapproval, difficulty expressing disagreement, being excessively devoted
to work and productivity, and being preoccupied with details, rules and
lists.
For children, signs of disorder occur when they are deceitful, break rules,
can't sit still or wait in lines, have trouble with math, don't pay
attention to details, don't listen, don't like to do homework or lose their
school assignments or pencils, or speak out of turn.
Granted, one momentary feeling or behavior will not qualify you as having a
DSM mental disorder; it requires clusters of them, usually for several
weeks, accompanied by some level of discomfort. Nevertheless, as Freud
suggested, the signs of potential pathology are everywhere.
The vast broadening of the definition of mental disorders has its skeptics,
myself included, who are suspicious of the motivations of the APA and the
drug companies that may view the expanding sweep of mental disorders like a
lumber company lusting after a redwood forest. But unlike the environment,
with its leagues of watchdogs, the medicalization of human foibles has few
challengers. That's too bad: The misdiagnosis of mental illness often leaves
a lasting trail in medical records open to schools, employers, insurance
companies and courts.
Does it advance psychiatry to view an increasing expanse of human troubles
as the expression of psychopathology rather than as part of the texture and
diversity of life? Psychiatry once focused on the prevention and treatment
of serious behavioral problems, of which there are plenty. But based on the
metastasizing DSM, the psychiatric association appears to be caught up in a
contemporary narcissistic quest for individual perfection.
The grand American experiment once was an attempt to structure our social
and political institutions to create a more civil and just society. Perhaps,
frustrated that we still contend with gross inequality, stinging poverty and
rampant political and corporate corruption, we now embrace the
perfectibility of individuals, not social institutions.
The public is being asked to swallow the view that all manner of human
troubles — from anxiety, interpersonal squabbles to misbehavior of many
kinds — be viewed not as inevitable parts of the human comedy, but as
psychopathology to be treated, usually with drugs, as expugnable illnesses.
The implicit ideal — the healthy, normal and truly happy camper — will,
properly medicated, harbor no serious worries or animosities, no sadness
over losses or failures, no disappointments with children or spouses, no
doubts about themselves or conflicts with others, and certainly no strange
ideas or behaviors. Their moods will be perfectly controlled in all
circumstances, and bad hair days will be things of the past.
Is it inevitable that the rest of us, the recalcitrant, flawed resisters to
the movement for individual perfection, will show up in future counts of the
mentally disordered? Count me in.
