Diagnosis

Pathologizing the norm: Follow-up

For those of you who are interested in this debate, there's a great new two-part article in the New York Review of Books by Marcia Angell questioning "The Epidemic of Mental Illness". The articles summarize three new books concerned about the prescription frenzy we are in the midst of and how this reliance on psychoactive medication came about. She addresses the problem of dealing with psychiatric disorders as chemical imbalances and the dubious efficacy of these drugs at actually improving symptoms at all. I highly recommend this read, as well as the second part in the series on "The Illusions of Psychiatry", for anyone concerned about our mental health system. One of the most resounding points she makes in this second piece is the perpetual expansion of the diagnoses listed in the American Psychological Association's Diagnostics and Statistical Manual (DSM). With every publication of the DSM there are more and more "disorders" that we have pathologized and created, and with the upcoming publication of the DSM-V it is certain that there will be a slew of new problems we can claim for ourselves and put a name to. Angell succinctly describes this problem stating, "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."

Finally, she brings to task the drug companies who are more involved in psychiatric treatment than in any other medical field. This applies not only to clinicians or psychiatrists with private practices, but also the research institutions, hospitals, universities, policy makers, patient advocacy groups, educational organizations and the APA itself.

Angell's writing takes a good hard look at the system of mental health, and while at time she makes some uncomfortable points, these are important questions that need to be addressed.

(Thanks to Emily Barnet for the Angell articles.)

Pathologizing the norm

Going in to any introductory psychology course, students are warned that the basic education they are gaining does not make them experts in the field. They are cautioned against diagnosing friends and family members with their scant knowledge and are reminded that there are many nuances of both personality and personality disorders that they are far from privy to. A stirring op-ed piece in the New York Times recently highlighted the perils of the common citizen diagnosing themselves and their loved ones with Alzheimer’s disease or dementia. However, more and more it seems that clinicians and researchers in the field of psychology and psychiatry are at risk of making this same mistake by pathologizing natural neuropsychological slips and common cognitive errors. Neuropsychological assessments involve a series of challenging, and at times painstaking, tests of memory, decision-making and cognitive flexibility, among other executive functions. Standardized ranges are provided for these scores from the wider population, much as for an IQ test. These assessments are particularly useful in neurological patient populations (such as victims of a stroke or a brain tumor) and the elderly to assess cognitive decline, just as the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) and MMPI (Minnesota Multiphasic Personality Inventory) are helpful in a therapist or clinician’s office. However, these tests, as well as “significant” real-life examples are now being used as evidence of disorder in normal individuals.

Nowadays, misplacing your car keys can be seen as a precursor to dementia, and blanking on an old acquaintance’s name is indicative of Alzheimer’s. Likewise, niche expertise is an example of savantism and social awkwardness a sign of long undiagnosed Asperger’s syndrome, which is just a short step away from autism on the spectrum.

But this is what we have to remember and what is getting lost in this dichotomous system of diagnoses: all of these disorders or impairments lie on a spectrum. And the ultimate litmus test for a disorder is not how poor one’s verbal recall is, but instead how much distress this impairment causes. The world of psychiatric and neuropsychological diagnoses is far from clear-cut and these classifications must be based on more than just behavior. The perception and attitude of the patient must be taken into account, including whether this person even considers themselves to be a patient in the first place.

Similarly, over the past twenty years the diagnosis of ADD/ADHD (attention deficit / attention deficit hyperactivity disorder) has risen dramatically, as has the subsequent backlash against over-diagnosing and over-medicating society’s children. Before running to the doctor's office or the prescription pad, it is important to remember that kids are squirmy, and that no one, college students and professors alike, can maintain disciplined attention during a tedious lecture.

Everyone experiences memory loss as they age, just as we all feel sadness over the course of our natural cycle of emotions. Unhappiness is a universal human feeling that everyone must go through from time to time, and is not indicative of the pervasive demoralizing morose of true depression. Emotion, attention and memory are all fluctuating human traits and must be remembered 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 release. But sometimes it is important to experience these sentiments, to sit and work through our problems and wrestle with our shortcomings. This is in no way meant to minimize the tribulations that accompany these very real disorders, but to serve as a reminder that all of us are flawed, mentally, physically and emotionally, and if we pathologize these feelings, these struggles, then we may  miss out on the robustness of life.