Some of the disorders added to DSM editions are primarily—or wholly—medical in nature. One example is the diagnosis of “breathing-related sleep disorder,” which arises from medical problems that interfere with sleep. One such medical problem is obstructive sleep apnea, which occurs when the muscles of the throat relax so much during sleep that they narrow or block the airway. Throughout the night, people with obstructive sleep apnea have their deep sleep cut short as they relax because they stop breathing; once in a lighter phase of sleep, they breathe normally again. This disorder is not a mental disorder, but a medical one.
Another example is the “disorder” “caffeine intoxication,” characterized by at least five symptoms after consuming the equivalent of two to three cups of coffee: restlessness, gastrointestinal problems, difficulty sleeping, nervousness, and rapid heartbeat. To meet the diagnosis, the symptoms must impair functioning in some way. It’s hard to believe that an episode of too much coffee or Red Bull constitutes a mental disorder, but there you have it. DSM-5 has added “caffeine withdrawal” as a diagnosis—characterized by a withdrawal headache plus at least one other symptom, such as drowsiness, that interferes with some aspect of functioning. With disorders like this in the DSM, it’s no wonder that half of Americans will have a diagnosable disorder in their lifetimes. The wonder is why more Americans won’t!
In addition to classifying some medical disorders as mental disorders, the DSM also has been nibbling at the edges of “normal” by reclassifying as pathological the patterns of thoughts, feelings, or behaviors that were previously considered normal (albeit perhaps weird or odd). For instance, people who are extremely shy and concerned about how others might evaluate them, and who thus avoid certain types of activities, might be diagnosed with “avoidant personality disorder.” These same characteristics didn’t used to be considered pathological, and in some other cultures they are not considered to be so.
Another way that the increased prevalence of mental illness occurs is by lowering the threshold of what it takes to be diagnosed with a given disorder. For instance, DSM-5 will change in the criteria for “generalized anxiety disorder,” a disorder that involves excessive and persistent worrying. Whereas the criteria in DSM-IV required three out of six symptoms of worrying, only one symptom is needed in DSM-5. Similarly, whereas in DSM-IV the symptoms must have persisted for at least six months, in DSM-5 the duration has been reduced to three months. So if you are excessively worried for three months about your finances or your health or that of a family member (to the point where you can’t control the worries), you would be considered to have a disorder, whereas in the past you would not have.
One effect of a bigger mental illness tent is that there are fewer people standing outside the tent. Although the next edition of the DSM might not increase the overall number of disorders, if the criteria are loosened (that is, if it takes fewer symptoms or less severity to meet the criteria for diagnosis), then more people would qualify for a disorder. There are, and probably will continue to be, fewer and fewer people who will live their lives in relatively good mental health according to the DSM.
The normal trials and tribulations of life—the periods of sadness, or worry, of anxiety, or grief, of difficulty sleeping, of drinking too much caffeine or having caffeine withdrawal headaches—have been pathologized. They’ve been made into mental illnesses. More “normal” thoughts, feelings, and actions have come to merit a diagnosis. This way toward providing a bigger tent for mental illness leaves us with an increasingly restricted definition of mental health and can make us all more likely to see mental illness even when it isn’t there—where there is just normal human struggle. We can become so used to seeing psychopathology that we think—erroneously—that being odd or having difficulties must be an expression of mental illness.
What is going in our culture that allows for this expanding definition of mental illness? There are many explanations. The first is related to payment for treatment. Psychological treatments and medications can be useful for a variety of problems, but for those treatments to be even partially paid for by health insurance companies, the problems must have a diagnosis. It’s not enough that there’s a problem that’s being addressed. It has to be a problem. (Of course, if you treat a problem before it becomes a mental illness, the health insurance company will have ended up saving a significant amount of money, but they don’t pay for early mental health intervention—there has to be a problem. But that’s a story beyond the scope of this article.)
Second, pharmaceutical companies search for ever-wider markets for their products. When more people are diagnosed with a given disorder (perhaps because of less stringent criteria), or a new diagnosis is created, it widens the market for their drugs. They push for “off-label” uses of their medications that in some way reduce a problem, and then they push for that “problem” to be redefined as a problem. In fact, DSM-5 and the pharmaceutical industry have a significant number of connections: One study found that 70 percent of DSM-5 task-force members have financial ties to the pharmaceutical industry.
Third is increased work expectations. The pace and demands of many jobs have increased. Many companies maintain as few workers as possible to get the work done, and if an employee can’t reliably perform up to the (more intense) pace, he or she risks getting fired. If an employee has been feeling “down” or “anxious” enough that it’s not possible to work at near 100 percent or even 90 percent productivity, a pill that promises to counteract the symptoms of a newly identified psychological disorder seems like a better alternative than limping along, worried about being fired on top of other problems.
Fourth, in our era of instant gratification, ushered along by online shopping, downloaded entertainment, and the immediate access to the world available through the Internet, if we have problems, we want a quick fix. If a medication will help lessen uncomfortable thoughts or feelings or maladaptive behavior, we are receptive to medication. To quote Sami Tamimi, an adolescent psychiatrist in the United Kingdom, “Like fast food, recent medication-centered practice comes from the most aggressively consumerist society (USA), feeds on people’s desire for instant satisfaction and a ‘quick fix,’ fits into a busy life-style.” But if we’re going to take a medication, we need to have a problem that is being treated—at least to get those doctors’ visits reimbursed by the insurance company.
Fifth, certain diagnoses—along with other criteria—make the sufferer eligible for government services or programs or supplementary educational services, or allow them to claim legal rights of nondiscrimination. People who feel they or their loved ones could benefit from those services may advocate for a widening in criteria that enables more people to be diagnosed and thus eligible for those services. For instance, the diagnostic criteria for autism will change with DSM-5, and people diagnosed with the disorder—per DSM-IV—and their loved ones have vociferously expressed their concern that the new criteria will be more restrictive and thus will exclude some who currently have the diagnosis.
Finally, I think there is an additional reason: As our lives take on an even more frantic pace and our workload becomes ever greater, having a diagnosis gives a name to the suffering we feel and the hope that with a label can come relief. In dark or difficult times, hope is essential. But I’m not sure that ultimately labeling half of us with a mental disorder is the best way to give people realistic hope. Having a diagnosable mental illness has almost become the new “normal.” As a society, we have an opportunity to think about how we define mental health and illness. It shouldn’t only be up to the authors of the DSM.
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The Actual World
“Mount Thoreau” and the naming of things in the wilderness.