Pathologising the Norm: The spread of mental illness

ONE IN FOUR of us will struggle with a mental illness this year, the most common being depression and anxiety. The upcoming publication of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) will expand the list of psychiatric classifications, further increasing the number of people who meet criteria for disorder. But will this increase in diagnoses really mean more people are getting the help they need? And to what extent are we pathologising normal human behaviours, reactions and mood swings?

The revamping of the DSM – an essential tool for mental health practitioners and researchers alike, often referred to as the ‘psychiatry bible’ – is long overdue; the previous version was published in 1994. This revision provides an excellent opportunity to scrutinise what qualifies as psychiatric illness and the criteria used to make these diagnoses. But will the experts make the right calls?

The complete list of new diagnoses was released recently and included controversial disorders such as ‘excessive bereavement after a loss’ and ‘internet use gaming disorder’. The inclusion of these syndromes raises the important question of what actually qualifies as pathology. Are we really helping more people by expanding these diagnostic criteria, discovering problems that were always there but previously unaddressed, or are we just creating new problems that now need to be treated? Moreover, the crucial questions of what these treatments entail and who will really benefit from them needs to be asked, not only for these new diagnoses but for our mental health care system as a whole.

There has been an explosion in psychiatric diagnoses over the last 30 years, due in large part to a change in ethos in the treatment and research of mental illness. This began in 1980 with the publication of the DSM-III, the first major revision of the manual to consider psychiatric disorders as physical diseases with biological origins, rather than mental illnesses stemming from intra- and interpersonal roots. This shift coincided with the development of the first effective psychiatric drugs (e.g. Prozac), thus enabling psychiatrists to prescribe medicine in treatment rather than relying on cognitive or psychoanalytic talk therapies. Since then, psychiatric diagnoses have more than doubled in the last 25 years, with this trend especially prominent in childhood disorders.

Attention deficit hyperactivity disorder (ADHD) is particularly exemplary of this phenomenon, with diagnoses skyrocketing over the last 10 years, up 66 percent in the United States since 2000. This may be partially due to a recent change in the diagnostic guidelines from theAmerican Academy of Pediatrics, suggesting that children as young as 4 and as old as 18 be screened and treated for the condition (ADHD was previously only diagnosed in children aged 6-12). Widening this age gap may enable parents to start seeking help for a troubled child earlier on, or include adolescents and adults previously thought to be too old to have ADHD, thus contributing to the increase in numbers. However, it is unlikely that this age change alone explains the ADHD boom.

Accounts by parents and clinicians alike suggest that the more common diagnoses of ADHD become, the easier they are to obtain. The spread of the disorder seems to have taken on epidemic proportions, stretching across geographical and socio-cultural boundaries. As such, acquiring a classification of ADHD has become remarkably easy. Diagnoses are made based on a clinician’s observations and subjective self-reports from the child, alongside comments and complaints from teachers and parents. There is no chemical or objective diagnostic test to identify ADHD, just as there are no such tests for the vast majority of psychiatric disorders. Clinicians must instead base their decisions on the symptoms described by the patient and his or her parents, matching their complaints to the criteria listed in the DSM. While this practice can be seen as progressive, giving those in need easier access to the treatments they require, it can also result in the undesirable consequence of widespread over-diagnosis in those who would not have originally qualified for the disorder.

This increase has also resulted in a dramatic rise in the number of prescriptions for psychostimulant medications used to treat ADHD, up 375% as of 2003. Pathologising and subsequently prescribing medication to help control a ‘problem child’ is a worrying side effect of the broadening of diagnostic criteria. A concerning trend has emerged for parents to give their children psychostimulant medication to treat inattention or hyperactivity in school, without an official diagnosis of ADHD. Clinicians willing to go along with this practice believe that these sub-threshold children can benefit from the calming and focusing effects of the drugs, and that they will help improve their academic performance. However, this seems a highly dubious practice, as the referring clinician may have a financial investment in writing these prescriptions, receiving perks or consulting fees from the very drug companies whose medications they are prescribing. This conflict of interest can significantly contribute to the free-flowing prescriptions for psychoactive medications, particularly in cases where the full-fledged diagnosis of ADHD is not warranted.

Another concern is that these behaviours – being rowdy or not paying attention in class – are actually manifestations of more serious problems at home, such as neglect or abuse. A child acting up is seen as disruptive and inattentive rather than crying out for help, and in many instances it is far easier to prescribe a child a behaviour and mood-altering drug than to confront a delicate situation at home. Similarly, another studyfound that younger children were disproportionately more likely to be diagnosed with ADHD than older students in the same class, indicating that maturity levels developing with age play more of a role in self-control and attention than underlying neurobiological conditions.

This is not to say that ADHD is not a real problem for many children, most commonly young or adolescent males. ADHD has well-established neurobiological roots, including structural abnormalities in the prefrontal cortex, an area of the brain involved in self-control, planning and decision-making. Individuals with ADHD have been shown to havereduced cortical volume in these prefrontal areas, resulting in increased impulsivity and poor self-regulation. However, the prefrontal cortex is also the last area of the brain to develop in all individuals, meaning that children and adolescents are inherently at least mildly impulsive by nature. Other more reward-driven areas of the brain develop much earlier during adolescence, while the self-control and future planning centres take longer to mature. This makes adolescents particularly prone to impulsive or risky behaviours, less able to control their actions or desires. Therefore, it can be difficult to determine how much behaviour is due to a chemical imbalance or structural abnormality, and how much is chalked up to normal curiosity or risk-seeking during anaturally explorative period of development.

ADHD symptoms have also been linked to an underlying reduction in the neurochemical dopamine. Dopamine acts throughout the brain, helping to facilitate learning and working memory, as well as being crucially involved in the brain’s reward system. Individuals whose bodies produce too little dopamine can have difficulty concentrating or staying on task, and they are often easily distracted by outside stimuli. They can also be overly impulsive, potentially resulting in poor decisions.

The stimulant medications used to treat ADHD work by increasing dopamine levels in the brain, in an attempt to improve attention and decrease impulsivity. However, these dopamine-enhancing drugs are chemically very similar to recreational stimulants, such as amphetamine or cocaine. An important question regarding these amphetamine-based medications, such as methylphenidate, is the addictive potential of these drugs. Prescription stimulants have started to be used recreationally by individuals without ADHD, creating similar ‘highs’ to their street-drug counter-parts, and raising concerns about the possibility of prescription drug abuse. While these medicines can help individuals with low endogenous levels of dopamine to focus and perform better at school, these drugs can have the opposite effect in persons with naturally higher levels of the neurotransmitter, increasing their energy levels and potentially over-stimulating them.

It is also yet to be determined what the long-term consequences (if any) may be from years of prescribed stimulant use, particularly from an early age when the brain is still in development and thus more malleable. Commonly abused stimulant drugs, like cocaine, are known to have serious adverse effects from chronic use. This includes furtherderegulation of the dopamine system via a decrease in receptor cell sensitivity, as well as additional reductions in prefrontal cortex volume. It remains to be seen if patients with ADHD prescribed psychostimulant medications will demonstrate similar long-term effects in the frontal cortex and dopamine system as chronic cocaine or amphetamine users, or if the brain’s ‘need’ for these chemicals will protect it from disadvantageous neural adaptations.

As well as the rapidly increasing number of children with ADHD, there has similarly been a dramatic rise in the number of autism disorder diagnoses made over the last decade. The inclusion of less severe symptom expression on the autism spectrum has led to a 78 percent increase in diagnoses in 8 year-olds in the United States since 2002, up to 1 in every 88 children. Previously, a diagnosis of autism typically included extreme intellectual disability or verbal deficiency, in addition to the social and communication difficulties most prevalent today. However, according to one report, only one third of those currently diagnosed with autism would qualify as having any intellectual disability, as opposed to more than half of those diagnosed ten years ago.

The wide variation in the manifestations of autism is a cause for concern among some clinicians. Similar to most psychiatric disorders, there are no hard biological diagnostic criteria for the disease, and evaluations are made using behavioural history, self-reports and family interviews. While more severe cases include complete non-verbal abilities and mental retardation from slowed cognitive development, the social retardation more commonly characteristic in individuals with autism today can be harder to identify and diagnose. In the upcoming DSM-V, the diagnostic criteria have been expanded even further, now including Asperger’s syndrome as a high-functioning form of the new autism spectrum disorder, rather than its own distinct diagnosis. Asperger’s typically involves difficulty with emotion regulation and an inability to read facial expressions or social cues, problems that can be quite painful for individuals and families struggling with the disorder, but are perhaps not on par and warranting of the same diagnosis as those patients with more severe cases of the disorder.

With the loosening of symptom severity criteria, families and individuals who have always felt there was something ‘off’, whether it be problems regulating behaviour and emotions, or difficulty communicating and relating to others, have a name for their struggles. For these individuals, it can be a relief to finally have an official classification for a problem they always thought existed, not to mention a label to provide to insurance companies and government-funded programs that help foot the bill for clinical treatments. Similarly, for very young children already showing signs of poor verbal abilities or social skills, there is greater opportunity to start treatment early and potentially head off or prevent more severe problems in childhood and adolescence. However, to others a diagnosis of autism in seemingly merely ‘odd’ children can create a sense of learned helplessness, enabling excuses for a socially awkward child or causing parents and teachers to treat him or her as ‘different’ instead of working harder to integrate him or her into the classroom.

An important question that needs to be raised regarding these recent increases in psychiatric diagnoses is what role does the multi-billion pound pharmaceutical industry have in this trend? With the rise in diagnoses comes a spike in prescriptions, poising pharmaceutical companies to make millions off the expansion of these varying diagnostic criteria.

This is particularly applicable in the recent changes made to the qualifications for clinical depression, with the DSM deciding to drop the exclusion of bereavement in its classification of the disorder. This means that individuals going through the natural grieving process following the loss of a loved one can now be prescribed anti-depressant drugs to help them cope. In the previous version of the DSM, only cases of ‘excessive bereavement’ (severe depressive symptoms lasting longer than eight weeks) were covered under the criteria for depression, enabling those who needed help to receive it, but without truncating or pathologising the normal grieving process. However, doing away with the time restriction and enabling those experiencing sadness immediately following the death of a loved one to receive pharmaceutical treatment unnecessarily medicalises this process. Additionally, the antidepressants prescribed in these situations (usually serotonin reuptake inhibitors, or SSRIs) are not entirely innocuous, and can be accompanied by unpleasant side effects. Furthermore, SSRIs can take up to four weeks to have full effect, and prescriptions usually last for several months. Thus, the immediate benefit to the patient when they need it the most would be limited, and it is likely they would be on the medication for longer than necessary.

The Washington Post recently investigated the decision behind this change and discovered that 8 of the 11 members on the board of the APA, the American Psychiatric Association, who were responsible for the revisions to the DSM have various financial ties to several different pharmaceutical companies. These include owning stock options, receiving consultation fees, and obtaining grant funding from the industry. These conflicts of interest can create serious potential bias in those members to best serve the financial interests of these companies; and in the current dilemma regarding the medicalisation of bereavement, the potential increase in profit from the rise in prescriptions is tremendous, almost undoubtedly influencing the decisions of those on the board. Furthermore, one of the chief advisors to the committee was the lead author of a study promoting Wellbutrin, an antidepressant drug developed by GlaxoWellcome, as an effective treatment for the alleviation of depressive symptoms following the loss of a loved one. The consultation from this individual, who could benefit both personally and professionally from such a change, was clearly biased in this situation, and most likely ended up swaying the board’s decision to its present outcome.

While no one is arguing against relieving the pain of those with prolonged or excessive suffering, there are serious concerns that arise from medicalising natural responses to loss and manipulating the normal healing processes. Dr. Allen Frances, a professor emeritus at Duke University who led the previous revision of the DSM, described the change as ‘legalizing the marketing of grief as depression’, and a recent editorial by The Lancet states:

Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed. The evidence base for treating recently bereaved people with standard antidepressant regimens is absent. In many people, grief may be a necessary response to bereavement that should not be suppressed or eliminated.

The implications of medicalising bereavement are currently unknown, but there is intense concern among clinicians that this could potentially prolong the healing process, preventing individuals from working through the natural cognitions and emotions involved in grief, and impairing their coping with sorrow and loss.

This tendency to add new disorders to the official list of psychiatric diagnoses is nothing new, with 100 conditions being compiled between the third and fourth editions of the DSM. But are we pathologising normal human behaviours, reactions and mood swings? Dr. Marcia Angell, a senior lecturer at Harvard Medical School and former editor of the New England Journal of Medicine, recently took this trend to task in a pair of articles for the New York Review of Booksstating:

Unlike the conditions treated in most other branches of medicine, there are no objective signs or tests for mental illness – no lab data or MRI findings – and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology.

Expansions in psychiatric diagnostic criteria, and subsequent increases in patient numbers, mean that many individuals are finally receiving the help they need. But there is also the concern that we are now medicalising, and subsequently commoditising, normal social slips and common cognitive errors. Everyone experiences moments of awkwardness in new social settings, just as we all feel sadness over the loss of a loved one. Emotion, attention and memory are all fluctuating human traits and must be considered as just that, natural and transient. Our culture is so eager for a quick fix, to get rid of any feelings of discomfort and receive instant relief. But instead of running to the doctor’s office or prescription pad at the first sign of a problem, it might be important to experience these emotions, to sit and work through our issues and wrestle with our shortcomings.

This is in no way meant to minimise the tribulations that accompany these very real and at times debilitating disorders, but to serve as a reminder that all of us are flawed, mentally, physically and emotionally, and if we pathologise and medicalise these feelings, these struggles, then we may miss out on some of the beautiful robustness of life.

Dana Smith

PhD student in Experimental Psychology at the University of Cambridge