In fact, psychiatrists have no good answer, and the boundary between mental illness and normal mental struggle has become a battle line dividing the profession into two viscerally opposed camps.
On one side are doctors who say that the definition of mental illness should be broad enough to include mild conditions, which can make people miserable and often lead to more severe problems later.
On the other are experts who say that the current definitions should be tightened to ensure that limited resources go to those who need them the most and to preserve the profession’s credibility with a public that often scoffs at claims that large numbers of Americans have mental disorders.
The question is not just philosophical: where psychiatrists draw the line may determine not only the willingness of insurers to pay for services, but the future of research on moderate and mild mental disorders. Directly and indirectly, it will also shape the decisions of millions of people who agonize over whether they or their loved ones are in need of help, merely eccentric or dealing with ordinary life struggles.” (New York Times )
The issue is heating up right now in the runoff toward the next edition of the American Psychiatric Association’s DSM (Diagnostic and Statistical Manual), due in 2010 or 2011. The DSM is the ‘bible’ which defines official mental disorders and their ‘official’ limits. There has been a tension ever since the beginnings of clinical psychiatry between lumpers and dividers. The former leads to contraction of the numbers of diagnoses, each of which has a broader scope, while the latter leads to the proliferation of narrow pigeonhole diagnoses. This also has some relationship to the tension between those who believe in qualitative differences between pathology and normalcy and those who believe in a continuum between more and less disturbed. Finally, this also maps to a difference between those who believe in treating psychiatric ‘diseases’ and those who target every symptom independently.
Diagnostic attitudes in modern psychiatry are, unfortunately, also strongly influenced by market pressures by psychopharmaceutical manufacturers, muddying the waters. As I am fond of saying, if the only tool you have is a hammer, it pays to see more and more nails around you everywhere. The Boston psychiatric establishment, where I practice, has a reputation of being at one extreme of the psychopharmacological continuum of disregarding diagnosis or putative disease process in favor of treating ‘target symptoms’, i.e. throwing a medication at every aspect of behavioral disturbance a patient demonstrates. The consequences are predictable. Patients come in with an obscenely lengthy roster of medications (and an obscenely weighty roster of side effects and complications!). New medications are usually added, and dosages of existing ones jacked up, as new distress emerges but the list is rarely pruned back when the patient is stable. The industry reaps the profits while the patient often suffers slowed and impaired thinking and activity; obesity and metabolic disturbance; sexual dysfunction and/or neurological damage. The intent of the DSM was supposed to be that clinically valid diagnosis would drive therapeutic decisions, not the other way around.
I have also written about another consequence of clumsy and slapdash diagnosis not driven by thoughtful clinical reasoning. Patients with personality styles, or personality disturbances, who are disinclined to accept responsibility for their behaviors, find it quite easy to obtain an ‘objective’ diagnosis of a disease to ‘explain’ their ills and let them off the hook for their behaviors or their recovery. Naive inexperienced clinicians (and let us not fool ourselves, a large majority of modern mental health treatment is delivered by trainees or therapists otherwise inexperienced!) ‘enable’ and collude with diagnosis-seeking by personality-disordered patients or, in some cases, push diagnoses on patients by their own initiative. The proliferation of the diagnosis of ADHD in adults is the most recent phenomenon of this sort. I have also written about the kneejerk, excessive labelling of patients with the diagnosis of PTSD (post-traumatic stress disorder). This is somewhat related to the phenomenon of ‘cosmetic psychopharmacology’, a term coined by psychiatrist Peter Kramer, atuhor of Listening to Prozac, who wrote of his concerns about the erosion of the boundaries betweeen the legitimate treatment of suffering and the more questionable practice of performance-tweaking with new-generation antidepressants. We should not necessarily use them in all cases where we might use them, where they are capable of having an effect, he might have said. If anything, the practice has only proliferated and the boundaries further eroded in the decade since Kramer raised the hue and cry. (Of course, there are now at least half-a-dozen new-generation antidepressants whose manufacturers are vying for market share, not just Prozac!)
Of course, when it comes to diagnostic practice, the converse is true as well, and I have written about this too. When a clinician who is not astute about his or her own reactions to the patients s/he treats (so-called “countertransference” feelings) takes a dislike to a patient s/he finds disagreeable or unruly, the patient is often given a pejorative personality disorder label, usually borderline personality disorder, while a legitimate mental illness they are suffering may consequently go unrecognized, undiagnosed and untreated.
Perhaps more important, then, than a consensus on the scope and number of official diagnoses would be the thoughtful, systematic application of existing diagnostic criteria to the process of labelling someone with a mental disorder. In fact, only accurate thoughtful diagnosis by experienced clinicians willing and able to avoid labelling someone on the basis of intuitive gut reactions (or other influences such as the marketing pressures from the pharmaceutical reps who visited them in the preceding week) will be the stepping stone on whose back we can begin to refine the diagnostic process and categories reasonably. I am at a loss as to how that might happen in time for the next edition of the DSM, which will guide at least the next decade of treatment (and funding of treatment) in mental health.
