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.
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