The ever-expanding world of mental illness

Britain’s newspapers have been full of predictions this week about 2012, when London will host the Olympics. There is a sense both of excitement over potential success and trepidation over potential failure, both on and off the sporting field. It is too early to predict with any confidence whether the London Games will be a success or not, but one thing I can predict, with utmost confidence, is that by 2012 many more of us will be defined as mentally ill.

This will not be related to the Olympics, but because 2012 is when the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (usually referred to by the shorthand DSM-V) is expected to be published. If previous revisions are anything to go by, then many more people will fall within the parameters required for a diagnosis of mental disorder (1).

It does not require a PhD in psychiatric history to be fairly certain that DSM-V will be more extensive than its predecessors. For example, between the first and fourth editions, published in 1952 and 1994, the number of pages grew from 130 to 886 and the number of diagnostic categories more than tripled. This led some sceptics to suggest, tongue only slightly in cheek, that at such a rate of growth we can reasonably expect the fifth edition to contain some 1,256 pages and 1,800 diagnostic criteria (2).

We have a few years to wait before finding out the exact contents. But it has been revealed in the US this week that there are already tortured discussions amongst those preparing DSM-V as to whether such things as overuse of the internet, ‘excessive’ sexual activity, compulsive shopping and apathy should be contained within the parameters of clinically diagnosable mental disorder in the next edition of the manual (3).

For example, there has also been much debate about the validity and/or expansion of the concept of post-traumatic stress disorder (PTSD), with a recent BBC Panorama programme detailing the expansion of the concept from extreme experiences (for example, war situations) to the more mundane (for example, minor traffic accidents, work stress) (4). At the end of that edition of Panorama, presenter Jeremy Vine said the APA was looking at tightening up the diagnostic criteria for PTSD in DSM-V. Time will tell if he is correct, but he is obviously unaware of post-traumatic embitterment disorder (PTED), an illness said to afflict those who remain bitter or aggrieved for too long about a past wrong, and which some psychiatric professionals wish to be included in the new manual (5). Good job this diagnosis wasn’t around for the year-long British miners’ strike of 1984-85.

In his 2007 book, Shyness: How Normal Behaviour Became a Sickness, Christopher Lane detailed how the medical profession and drug companies promoted their wares by reclassifying everyday anxiety and mild eccentricity as mental illness (so that shyness becomes ‘avoidant personality disorder’ or ‘social phobia’), and also documented the often chaotic, arbitrary and tactical procedures that accompanied the inclusion of certain diagnostic criteria within the creation of DSM-III in 1980. This was far from a rational, scientific, clearly defined process (6).

It is easy, and a lot of fun, to mock the excesses of such diagnostic expansion. There are also many ‘diagnoses’ not (yet) included in DSM classifications that are given credence by many mental health professionals. My personal favourite is the man, sacked from his job for being persistently late, who sued for unfair dismissal on the grounds that he suffered from ‘chronic lateness syndrome’. That’s one to save for the next time you sleep in.

Nevertheless, there are also some more serious issues that arise from the current situation in terms of personal autonomy, social understanding and political life.

For me, the changing cultural climate was highlighted by the differing reception for two books by the American literary critic and feminist, Elaine Showalter: The Female Malady (1985) and Hystories: Hysterical Epidemics and Modern Culture (1997). While the first book enjoyed much acclaim and is deemed essential reading for any serious students of the relationship between gender and mental health, the later one provoked much criticism, with Showalter having to encounter public protests at several post-publication promotional events.

The difference was not so much in what she was arguing, but in the cultural environment in which it was expressed. In many respects, Showalter was making the same point in both books: that what are often termed medical diseases or illnesses are actually the result of complex social, political and psychological processes that could get hidden under a psychiatric diagnosis. However, the later book was published in a climate far less amenable to deep searches for meaning in human experience. Instead, catch-all simple diagnoses and professional expertise, whether by way of therapy or medication, are now seen as holding the key to the understanding of human suffering.

It should be no surprise if some people, in an attempt to give meaning to their lives, use a dominant psychiatric framework in which to do so. The relative decline of past frameworks in which we situated ourselves (religion, political projects, nation, and so on) does not halt the search for meaning, and today we live in a period where mental health professionals, campaigners and government regularly inform us of our vulnerability.

Not only does this outlook pose problems for us as autonomous individuals as we adopt the role of Being Sick; the pathologisation of everyday life also undermines democracy, too. The concept of democracy rests on the assumption that we, as rational agents, elect and hold parliament to account. If, on the contrary, we are classed as irrational, as suffering from myriad mental disorders that limit our capacity and responsibility, then the basis of democratic accountability is seriously compromised. Instead of ‘we, the people’ holding the state to account, the state takes on the role of doctor caring for a vulnerable and irrational electorate.

This is illustrated not only by the expansion of psychiatric diagnoses, but also by the broadening definition of a ‘vulnerable adult’. In the 1990s, there was a fairly high threshold before someone qualified as a ‘vulnerable adult’. It was linked with clearly defined groups (for example, those in need of services due to mental or other disability, age or illness) who were at risk of suffering significant harm or serious exploitation. No doubt such a high threshold was used to withhold services from people who needed it, but it also reflected a view that to be vulnerable was not the norm.

However, over the years the authorities in Britain have reversed that viewpoint and exponentially expanded the numbers of people classified as a vulnerable adult. The definition now includes all disabled people, and virtually anyone in receipt of any form of health or social services or who is receiving treatment or therapy of any description. The idea that such groups are, by definition, ‘at risk’ is now so unquestioned that it does not need a mention. In effect, ‘vulnerable’ has become a noun. We all require the care of the therapeutic state.

It is clear that the government and many mental health professionals (although there are also many who are deeply concerned by current developments) have a low opinion of our ability to negotiate and transcend the problems of contemporary social and political life, and they have a vested interest in viewing us as sick and irrational. It should also be clear that allowing them to get away with this interpretation unchallenged poses a danger to our personal autonomy and political agency.

Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England. His book Social Work, Politics and Society: From Radicalism to Orthodoxy is published by Policy Press.

(1) The other classification system is the World Health Organisation’s International Classification and Statistical Definition (now in its tenth edition, hence ICD-10). Whilst DSM-IV is more common in the USA and ICD-10 more widely used in the UK and Europe, there is increasing interpenetration, with the APA being asked by the WHO to contribute to the ICD-10 chapter on mental disorders. DSM-IV is cited on the website of the UK Royal College of Psychiatrists, and was also referenced during discussions in the UK Parliament concerning the Mental Health Act 2007.

(2) Blashfield, R. and Fuller, K (1996) ‘Predicting the DSM-V’, Journal of Nervous & Mental Disease vol. 184, pp 4-7.

(3) See Bitterness, Compulsive Shipping and Internet Addiction: The diagnostic madness of DSM-V, Slate, 24 July 2009

(4) Panorama, 27 July 2009

(5) See Post-traumatic embitterment disorder: the newest mental illness?, Living the Scientific Life

(6) See Christopher Lane (2007) Shyness: How normal behaviour became a sickness, reviewed on spiked here.