Pathologising the norm: the spread of mental illness

Dana Smith
February 12, 2013

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 the American 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 study  found 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  have reduced 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 a naturally 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 further deregulation 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 Books, 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.

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.


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Dana Smith