If a chap is alone most days because he is single, divorced, unemployed, retired, aged, or any combination, he may feel down in the dumps at times. But that does not necessarily mean he is mentally ill, a ‘depressive’, with no existence outside the clinical text-book. If medical professionals only see the pathology and not the whole person he may suffer the effects of stigma added to the original problem. He still wants to be seen as a normal human, sometimes happy, sometimes not, rather than only a clinical stereotype.
Normal life varies for different people. Medical labels, especially with foreign names therefore of uncertain meaning, can imply folk living unusual lives are ‘sick’, ‘abnormal’, ‘need treatment’, thus reducing their sense of autonomy and self-confidence. If someone disturbs the peace blowing a bugle at 2am then public action may become necessary, but not permanent stigmata.
There has been a flurry of discussion in medical circles about the dangers of using diagnostic language loosely, to the detriment of a patient and patients generally.
Australia’s ABC Radio broadcast a discussion on 20 May 2013 entitled Normal Behaviour Defined as MentaI Illness. Presenter Emma Alberici interviewed Dr Allen Frances, supervisor of the latest edition of the American Diagnostic and Statistical Manual of mental disorders (DSM). Launched in 1952 with 106 conditions identified as mental illnesses the number has now more than tripled.
Alberici pointed out that Frances now condemns much of his own work. ‘In his new book Saving Normal Dr Frances argues there is now an increasing tendency to chalk up life’s difficulties to mental illness … We were very worried about diagnostic inflation in psychiatry and excessive treatment … but our conservatism was absolutely overwhelmed by drug company marketing’. Frances feared the DSM would turn what we consider everyday normal problems into mental disorder with excessive use of medications, harmful and very costly. For example turning normal grief into ‘major depressive disorder’, the forgetting of old age into ‘mild neurocognitive disorder’, worrying about your cancer into ‘somatic symptom disorder’, temper tantrums in kids into ‘disruptive mood disregulation disorder’.
“Attention deficit disorder will be virtually ubiquitous and an easy means of getting stimulant drugs for performance … and recreation”, he added.
Children are particularly difficult to diagnose, wrote Frances: ‘A kid may look disturbed this week and very much better two weeks later. So we should be especially cautious … there’s been a loosening of diagnosis and with it excessive use of medication for children who very much will likely do better without it. I believe in stepped diagnosis, caution, first do no harm, watchful waiting … get second opinions … see how things work out over time.’
On Attention Deficit Disorder Frances said ‘in its classic and severe form ADD definitely needs to be treated promptly. But the tripling of rates … means that many kids who don’t need diagnosis are being treated ... We’re turning being young into a mental disorder … We should be spending less money on drugs … [and] more [on] smaller class sizes and physical education so that kids can blow off steam.’
He said prevention is a wonderful idea ‘but what we‘ve learned from the last 35 years … is that very often the intervention is worse than the disease ... screening tests … are often more harmful than helpful … (in psychiatry), many of the interventions are themselves quite dangerous, especially medication.’
Dr Frances said particular care needed to be taken with people grieving following bereavement: ‘If you feel sad, … lose interest, appetite, have trouble sleeping, less energy just two weeks after losing the love of your life, that can be diagnosed as major depressive disorder and drug salesmen can try to convince doctors that medication is indicated. This is substituting a superficial medical ritual for the deep and important human cultural rituals around death that have been built up over hundreds of thousands of years. It’s normal to grieve. We shouldn’t be calling this mental disorder. We shouldn’t be treating it with medication, unless it’s severe’. Frances said there are symptoms that are a normal human response to the horrors of war: ‘But calling it mental disorder … often makes the problem worse.’
On the title of his book How do you save normal? Frances said ‘We need to tighten the diagnostic system … control Big Pharma … change insurance policies that encourage doctors to diagnose early in order to be reimbursed for the visit. Watchful waiting for mild problems often is the very best policy.’
Medical labelling as a punishment
A 75-year-old man is taken to a modern hospital with a broken leg, a big enough problem in itself, then he cannot immediately remember his son’s name and address or pass the common test of counting backwards from 100 in sevens. So he risks being assigned to the bin marked ‘Alzheimers’, with its odour of senility, memory loss, even insanity to add to the disadvantages of his wrecked leg. The patient now has more problems than he started with: the ongoing ageing process, the newly damaged leg, and now this mysterious new diagnostic label with a foreign name sitting like an unexploded bomb. A kind of spiritual life sentence. Does this new label help him feel better or worse? In his daily round Mr Brown does not feel sick, friends treat him as a normal person although none deny they are all getting older. Memory glitches go with the territory, but they cause giggles rather than despair. It is just one of many time-related phenomena such as no longer being an energetic footballer but instead moving like a tired old cripple.