Normal or Pathology?

Since the DSM 5 has been published, I’ve done a lot of reading. The battle continues to wage between proponents and opponents of the latest incarnation of psychiatry’s “bible” and it doesn’t look to be resolved any time soon.

For the record, I think of the DSM (in any of its flavours) as a tool, useful in some situations, harmful in others, no different than any other tool in any other profession.

Where I struggle with the whole business is the difference in perspective between psychology and psychiatry and how that impacts the people involved with either. I’ve taught my students for years that generally speaking, ‘therapists normalise and psychiatrists pathologise,’ and as far as I can tell, it remains a truism. The DSM 5 has swung the pendulum waaaaaaaay over to the ‘pathology’ side, and I’m not the only one unhappy about this.

Noah Rubinstein, Good Therapy’s founder, has been articulately vocal regarding his reservations about many of the changes in diagnostic criteria in the new version of the DSM, and I often find myself in agreement with his posts. Recently, I read yet another article about labelling, courtesy of the Good Therapy blog, this post by Lillian Rozin. The article itself is pretty straightforward – but it’s the comments afterward that were most engrossing, and focused almost exclusively on how people feel about being labelled.

“Labelling” is positive or negative depending on the perception of the one being labelled, and that perception is formed by culture, life experiences, societal norms, &/or family of origin, just to name a few influencing factors. What one person hears as a pejorative or demeaning categorisation, another hears as a relief; an answer to a mystery or worry that can now be understood and managed because it has a name.

Why does this matter?

Medicalizing normal experience stigmatizes and cheapens the human condition and promotes overtreatment with unnecessary and potentially harmful drugs. ~British Psychological Society

Individuals with mental health issues get shafted. Research data supports the reality that people who have been diagnosed with a chronic mental illness may receive substandard medical care, are regularly denied life-saving medical interventions, and die younger than a comparable individual without the psychiatric label – by an average of 8 years. While the label may have helped that person access treatment and/or community support for the mental illness, it probably didn’t particularly help with quality of life.

[T]here is sufficient evidence that people with SMI (severe mental illness) are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI. ~World Psychiatry. Feb 2011; 10(1): 52–77.

Mental illness is stigmatised (check out here, here, and here). Period. This is bad enough for people suffering from illnesses such as schizophrenia, bipolar disorder, or a personality disorder. To now have grief, temper tantrums, and unexplained physical symptoms labelled as “mental illness” is beyond discouraging. I admit – it got very personal for me when I saw the criteria for Somatic Symptom Disorder. What a nightmare. The year it took for me to be diagnosed with Multiple Sclerosis I met all the criteria for the old DSM IV diagnosis of Somatization Disorder – which would have been superseded immediately upon definitive confirmation of MS. Under the DSM 5 change to Somatic Symptom Disorder, I could still be labelled with this mental health disorder, in spite of the fact that all the symptoms present are accounted for by the diagnosis of a medical condition.

Back to the issue of labelling.

If I were diagnosed today as having MS, and SSD, the likelihood is that my medical symptoms would be taken less seriously, if not dismissed outright; I would be far likelier to wait for medical attention at the hospital, and much more likely to die of a treatable condition/disease because the medical community stigmatises those patients with co-morbid mental health diagnoses.

I find myself often wondering about the “other” side of the mental health/mental illness debate – those in the camp who say that mental illness is not really illness at all, but society’s rejection of those whose minds work differently, and who, as a consequence, do not follow cultural norms. This has come more often to mind as a I work in, and with, other cultures. What my culture would characterise as “mental illness” may be seen completely differently in another culture. The individual is not stigmatised, ostracised, or rejected by his/her family, social circle, or wider culture. 

I get that there is a LOT of gray in this issue, but I find myself spending more and more time reading about, and educating myself on, the NIMH intiative to develop Research Domain Criteria (RDoC), and the rationale behind the much more stringent diagnostic criteria of the ICD 10 (and soon-to-be-published ICD 11).

What good are we doing – or rather, what harm – are we doing by pathologising psychological and emotional distress? What if schizophrenia were accepted as an individual’s manifestation of a different mind? What if, in fact, our society’s rigidity in applying cultural norms is what actually produces the degree of dysfunction or impairment that is then used as partial justification of a diagnosis of a mental illness?

I’ve never been accepting of the speed with which people are labelled – for anything – and when that label immediately incurs other, more long-term risks to life and health, I’m definitely unhappy about that.

As always, I process by trying to write my thoughts in a somewhat linear order. Sometimes it works, sometimes, not so much. Still pondering.

More food for thought here, here, here, and here.

Talk amongst yourselves...

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