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The Normalization of Diagnosis

Posted Dec 03 2009 8:01am
A note: When I mention mental illness, assume I am talking about it in the most general way: Any condition that can be diagnosed by a psychologist; psychological, cognitive, or neurological. It takes too long to write that phrase out every single time I mention it.

Lots of people are getting upset about the proliferation of psychiatric diagnosis. It seems like everybody's kid has ADHD, autism, or dyslexia; and everybody who hasn't got depression probably has an eating disorder, bipolar disorder, or generalized anxiety disorder. And with every new decade, a longer list of diagnoses makes it into the manuals, and more and more people are labeled with them.

But that's crazy, isn't it? Only crazy people get diagnosed with psychiatric and cognitive disorders! You have to be really, really off your rocker to deserve a psychiatric label... or do you?

Well, no. Not anymore.

Psychology is a new science. Oh, sure, we always knew something was different about some people, and the explanations ranged from demon-possession to sainthood, or just being a woman (seriously, the name for "hysteria" comes from an old word for "uterus"); but it hasn't been until recently that psychology was anything approaching a science. Even Freud worked with nothing but case studies. The first working psychiatric drug was Thorazine in 1950--before that, there weren't even any useful medications. Even today, when you read the journal articles that deal with psychology, the writers seem almost desperate to quantify their research; and an entire branch of psychology deals with psychological testing--finding ways to make the evaluation and diagnosis of a patient more concrete, instead of subjective.

We're going through a transition in the field of psychology. Older generations have the idea that being diagnosed with a psychiatric/neurological/cognitive condition means that you must have a severe condition; because in the past, those were all that were diagnosed.

But the new diagnoses, in many cases, aren't severe or obvious. To the older generations, and some members of the younger ones, this must be quite confusing; because if you don't let go of the idea that a person must be a raving lunatic to qualify for a diagnosis at all, then you will be quite surprised to see seemingly ordinary people with diagnostic labels.

The new labels come from three basic categories1. New disorders that have only now become recognized as a distinct group.
2. Recategorization from what used to be labeled a moral failing.
3. Less severe versions of things we already knew about.

The newly recognized disorders are easy enough to explain. With people formally studying psychology for a century or so, attempting to categorize and understand the variations of the human mind, it is only natural that many such variations will have been newly categorized. Among these are schizoaffective disorder (a name for what happens when mood disorder gets combined with schizophrenia), PTSD (first identified in veterans), and seasonal affective disorder (recently distinguished from depression for its strong circadian-rhythm conection). Autism is in this category too; it was differentiated from schizophrenia and recognized as a neurological disorder rather than a psychotic disorder. People with these disorders would, in the past, have been known to have "something wrong with them", but no particular name would have been found, and most likely, they wouldn't have seen a psychologist.

Recategorizing what has been thought to be a moral failing in the past, but turned out to be something completely different, caused more problems for the psychology profession. Now they were stepping on people's toes; folks could no longer see the person whom they thought to be annoying, stubborn, or depraved, and look down on him. The problem was, of course, that most of these diagnoses weren't moral failings at all--they were simply explained as such. In this category are things like ADHD, selective mutism (this even used to be called "elective mutism" because it was thought the child chose to be silent), gender identity disorder, and many of the disorders related to sex and sexuality. Borderline, avoidant, and narcissistic, and histrionic personality disorders go into this category, too, and so does premenstrual dysphoric disorder (also known as severe PMS). Even actual moral failings--which psychiatrists recognized as moral failings but insisted on categorizing anyhow--were added to the list, in the form of conduct disorder and antisocial personality disorder.

The last group, and the one which seems to cause the most argument, is the group of milder disorders just being described, and milder cases of known disorders being diagnosed. Dysthymia and cyclothemia are long-term, low-level forms of depression and bipolar disorder. Schizotypal and schizoid personality disorders may be (or may not be) mild versions of schizophrenia. Asperger's, of course, is a milder variant of autism.

Many diagnoses have simply been expanded to include not just the cases where they cause near-total disability, but the cases where they cause distress and/or mild to moderate dysfunction. Now you can be diagnosed with OCD even if you aren't closeted in your house and spending all your time counting things; you can be diagnosed if you simply spend a few hours before and after work on your rituals, still managing to raise a family and keep a job but giving up your free time. You don't have to be completely unable to interact with the world to be diagnosed with depression; you just have to be in significant distress, even if you can still push yourself to get through your day.

All three groups, I think, are legitimate reasons to introduce new diagnostic categories. Differentiating disorders from each other, when they fall into distinguishable groups, makes a great deal of sense for the purposes of treatment (I've argued that Autism and Asperger's do not in fact fall into distinguishable groups; there may be others like this, but most of the ones I know about are in fact different and do fall into recognizable groups--autism and schizophrenia, for example, are demonstrably different.) And now that we know more about many diagnostic categories, it's no longer logical to call them moral failings--especially since many people with these diagnoses can be shown to have tried for decades to "overcome" their own "moral failings", with little success until outside help, medication, or a helpful environment are present.

If you can't change it, no matter how hard you try, then it can't be a moral failing--"moral" implies you have a choice. (It is, however, a moral failing to refuse to get help when you know your condition is hurting someone else.) Psychology can help these individuals by teaching new strategies, finding useful medication, or providing useful accommodations. What good is it to simply berate these people for being somehow deficient, if such an approach has never done much good, while helping them learn what they need (organization lessons for an ADHD kid, for example) tends to be at least moderately successful? The only benefit I can see to it is that people like to feel superior to others. The recognition that what most people do easily is difficult or impossible for people with various psychological diagnoses forces a change in perspective; after all, if it's easy for you to organize your desk, but takes your ADHD child six hours and maximal effort to do, can you really look down on him for having a messy desk? Nope. The proper approach is to teach him how to organize a desk. Suddenly, the easy, acceptable target is lost. That upsets some people.

(A word about conduct disorder and antisocial personality disorder: I do believe that people diagnosed with these make their choices, and hurt people willingly. They are not excuses for any of their actions. However, they can benefit, if they choose to, from therapy, because there are peripheral issues that can be addressed to allow them to make better decisions: Namely, self-inhibition; decision-making; understanding of consequences.)

The milder disorders seem to cause the most contention because they fly in the face of a stereotype we seem to hold dear: Mental illness is severe. It's obvious. It's rare. And it can't happen to me, because I'm more sensible than that.

It's true that for a long time, we identified only severe mental illness as mental illness at all; and identified only severe cognitive and neurological disorders as disorders. Epilepsy was only diagnosed if you had grand mal seizures; autism was only diagnosed if you couldn't speak; depression was only diagnosed if you couldn't take care of yourself or tried to commit suicide. However, this is an incomplete view of mental illness. Mental illness isn't present or absent, either causing severe distress or not there at all. There are in-between gradations, in which a person has significant difficulty, but doesn't yet need constant supervision. Think of physical illness and disability: There are gradations there, too. The common cold is just as legitimate a medical diagnosis as pneumonia; an incomplete spinal cord injury causing weakness in the legs is just as real as a complete SCI which requires a ventilator and wheelchair. Why should mental, cognitive, and neurological diagnoses be different?

That mental illness must be obvious (or, at least, be dramatically non-obvious until someone snaps and murders someone) is also quite a false stereotype. It does not need to be obvious. Many medical diagnoses are not obvious. Notably, high blood pressure can cause absolutely no symptoms. Diabetes can be silent, in its early stages. Most cancers don't show themselves for quite a while. A person can go about his business quite happily while infected with HIV. The reason we diagnose these problems is that they will eventually cause trouble, if left alone; and so it is with many psychology diagnoses. Learning disabilities will eventually cause a child to fall behind in school. Depression can worsen. It makes sense to do something about these things while they're still small and minimally harmful. (However: It's important to remember that psychological treatments, including the various therapies, are NOT free of risks and side effects, and should be pursued carefully, as any treatment should be.)

The fact is that mental illness is not rare--no more rare, anyway, than physical illness. While you may never have a mental/cognitive/neurological condition that requires intensive support, odds are that you or someone in your family does have, or will in your/their lifetime have, a legitimate psychological diagnosis--a condition that causes significant distress or dysfunction. It probably won't be severe. You may just have a child who needs extra reading lessons thanks to dyslexia; or you may have nightmares and flashbacks after being mugged. You might find that your brain doesn't deal with winter unless you get enough light. You might have problems getting over the baby blues and need an antidepressant. It's about time we stopped ignoring this real human suffering. After all, we don't ignore sprained ankles or high blood pressure just because they're not medical emergencies that require an ambulance and an ICU bed, do we? We shouldn't ignore these less-severe psychological/neurological/cognitive problems, either.

The transition we as a society are going through in regards to psychology is an awkward one: At the same time as the stereotype is still, "Mental illness is severe, obvious, rare, and morally questionable," we're recognizing that psychological, congitive, and neurolgical conditions aren't rare at all. People diagnosed with anything at all immediately get the idea that because they have a psychological diagnosis, it must be stereotypically severe. Because it's not obvious, many people think it must be fake. And because many people still think that these conditions must somehow be your fault, the tendency of a community to support physically ill members, at least to some extent, is nearly or completely absent for those with a psychological diagnosis.

I've heard a lot of jabbering that we should stop diagnosing so much mental illness, and stick labels only on the people who are obviously crazy. But why? People with milder problems do experience distress; and they can benefit from help. That's the definition of a sitution in which a diagnosis is helpful. It doesn't make sense. Instead of going back to a century ago, when only the "really crazy" people got what passed for help, we should make it known that it actually isn't such a rare thing to have a psychological diagnosis. Remove the stigma, and people will be free to think of having a mental illness as a problem like any other--bothersome, painful, but not something that defines your existence and means your life is basically over.

We're just going to have to face it: We're all a little crazy, and we all have the potential to have problems with various kinds of craziness. We shouldn't exclude people who do; we shouldn't deny our own problems. And, for their part, the psychology profession needs to stop taking themselves so seriously, assuming they're the saviors of all the poor crazy people out there. After all, the psychologists are probably a little crazy, too.
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