The
old adage about pornography was always “I know it when I see it.”
The same holds true for disorders of the mind. There is such a
range of human behaviour, most of it adaptive in at least one
particular circumstance, that defining mental disorders has always
presented a challenge. Our knowledge of the mind and behaviour is so
far behind our knowledge of human physiology that, to a dispassionate
observer, our categories and treatments appear as primitive as belief
in the four humours theory of disease which dominated medical thought
for 2,000 years. In many instances, our expertise is primitive and
based on untested and untestable theories. Mental disorders, in
absence conditions such as reactive depression (which will pass on
it’s own), are notoriously hard to treat. Medications are
imperfect, imprecise and cause side effects just as debilitating as
the disease itself, and cognitive therapies, such as CBT (cognitive
behavioural therapy) while offering the best option for many
conditions are constrained by the need for the sufferer to have
insight into their own condition, a characteristic which is notably
absent in many of the mental disorders.
In the modern world, the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric
Association has become the bible of diagnosis. The World Health
Organisation has a similar categorisation scheme (International Classification of Disease-11) and the overlap between the two is
considerable. The DSM is now on Volume Five, and, with each volume
produced, the categories and range of mental conditions has widened.
It is now – almost literally – possible to diagnose anyone with a
mental disorder, so broad and expansive have the categories become.
At a certain point, the nosology itself becomes disordered. Not
everyone who fidgets has ADHD
(Attention Deficit Hyperactivity Disorder), not everyone who feels
sad, has Depression,
and not everyone who is uncomfortable in large social groupings has
Social Anxiety Disorder.
The original intent of the DSM was to categorise the most serious
mental disorders to allow a common language and treatment across
providers, and to facilitate charging a fee for treatment. As with
many branches of medicine, the profit motive can easily commandeer
the best intentions, and, in the business of treating mental
disorders, the hijack is very nearly complete. Depression, for
example, can now be diagnosed after as little as two weeks. This, of
course, expands the pool of patients who can be prescribed treatment
and medication from a small percentage of the population to a much
larger and broader cohort. But it is not just business which drives
the expansion of diagnostic categories, “patient” advocacy groups
are also invested in expanding the pool of mental disorders to gain
more services and, in many cases, more political power.
Most mental disorders, however, are still diagnosed on the basis
of how much they impact the individuals life. This allows a spectrum
of behaviour to be considered normal, while the extreme outliers are
the focus of diagnosis and treatment. This is, of course, eminently
sensible, because, as with pornography, we all recognise the extreme
ends of human behaviour when we see them. Washing your hands before
preparing meals or after using the toilet is completely logical and
sensible behaviour. Washing your hands fifty times in one hour in a
very circumscribed routine no longer provides any benefit and is
actually harmful.
The paradoxical feature of mental illness in the post-modern world
is that we have expanded our categories of mental disorders such that
anyone with any quirk of behaviour (and we all have quirks) can now
diagnose themselves with something – the most popular currently are
ADHD, autism or more properly Autism Spectrum Disorder (this allows a
diagnosis without any impact on your life – real autism is
extremely debilitating), and the wonderful catch all “neurodivergent”
– without any requirement that a cure be sought after or attained.
With one of these popular mental disorders we can exist happily in
our uniqueness without the burdensome knowledge that our disorder is
limiting our lives in any way. In fact, our specialness becomes
something to celebrate as “diversity.”
Contrast this to pathological conditions of the body, such as
cancer. No-one celebrates a cancer diagnosis and, once diagnosed,
all but a very small minority of the population pursue a cure as
aggressively as possible. The post-modern mental health industry has
abandoned this model. Treatment and counselling is no longer about
challenging disordered beliefs to improve the individuals life and
has become instead a parade of affirmative action and the importance
of “lived experience” which over-rides the very real consequences
of untreated mental illnesses.
And again, we all know it when we see it. We all recognise when
obsessive and extreme behaviours are causing real disorder,
dysfunction and distress in the sufferers. At the extreme ends,
these disorders shorten people’s lives, while in the muddy middle,
life becomes a difficult dance of indulging obsessive behaviours
which immensely reduce quality, if not quantity of life, and have
very real and often physical sequelae. To the outside observer, this
is obvious, to the ego-syntonic sufferer their behaviour is eminently
defensible and, is frequently affirmed and even facilitated by mental
health professionals as a legitimate “lived experience” which
provides a unique but not pathological way of coping.
This is an extreme disservice to the afflicted. The behaviours do
provide some kind of mental relief to the person affected, just as a
hit of smack reduces withdrawal symptoms in the addict, but no-one
whose life is dominated by the outliers of human behaviour is in
anyway “living their best lives.” They are, in fact, as much
victims of compulsion as drug or alcohol addicts. Treatment is
painful. Entire fabrications and belief systems have to be
dismantled and replaced with more adaptive coping mechanisms, and
anyone who has done any mental work themselves understands that
rehabilitating unproductive and unhelpful beliefs and habits is much,
much harder than similar physical effort. Cancer treatments are
painful, debilitating, fraught with unintentional side-effects, and,
if improperly managed, fatal, and yet patients and providers alike
pursue treatment with vigour. We should demand no less of mental
health patients and providers.
Further reading:
The Age of Diagnosis: Sickness, Health and Why Medicine Has
Gone To Far. Dr Suzanne O’Sullivan.
Saving Normal: An Insider’s Revolt Against Out-of-control
Psychiatric Diagnosis. Dr Allen Francis.
The Repressed Memory Epidemic. Mark Pendergrast.
The Age of Diagnosis: Our Our Obsession with Medical Labels Is
Making Us Sicker. Dr Suzanne O’Sullivan.
