Are We All Going Mad, Or Are The Experts Crazy?

by Stuart A. Kirk

Psychiatric researchers recently estimated that half of the American population has had or will have a mental disorder at some time in their life. A generation ago, by contrast, only a small percentage of the American population was considered mentally ill. Are we all going mad?

Freud started this. He made us suspicious that any behavior was potentially rife with psychopathology. As a neurologist, he used the medical language of pathology to suggest that the demands of civilization on our fragile human nature were such as to make all of us somewhat neurotic.

The current psychiatric bible published by the American Psychiatric Assn, "The Diagnostic and Statistical Manual of Mental Disorders," or the DSM, continues this tradition of making us all crazy.

Because there are no biological tests, markers or known causes for most mental illnesses, who is counted as ill depends almost entirely on frequently changing checklists of behaviors that the DSM considers as symptoms of mental disorder. In the recent research, lay interviewers asked a sample of people to respond to lengthy questionnaires based on the DSM lists. Computer programs then counted the responses to determine if those interviewed had ever had the required number of behaviors for any mental disorder at some time in their life.

We keep getting higher estimates of mental disorders in part because the APA keeps adding new disorders and more behaviors to the manual.

Since 1979, for example, some of the new disorders and categories that have been added include panic disorder, generalized anxiety disorder, post-traumatic stress disorder, social phobia, borderline personality disorder, gender identity disorder, tobacco dependence disorder, eating disorders, conduct disorder, oppositional defiant disorder, identity disorder, acute stress disorder, sleep disorders, nightmare disorder, rumination disorder, inhibited sexual desire disorders, premature ejaculation disorder, male erectile disorder and female sexual arousal disorder. If you don't see yourself on that list, don't fret, more are in the works for the next edition of the DSM.

Because so little is known about the causes of most mental disorders, just about any behavior can look like a symptom. Here is a selection from hundreds of behaviors listed in the DSM, behaviors that signify one disorder or another: restlessness, irritability, sleeping too much or too little, eating too much or too little, difficulty concentrating, fear of social situations, feeling morose, indecisiveness, impulsivity, self-dramatization, being inappropriately sexually seductive or provocative, requiring excessive admiration, having a sense of entitlement, lacking empathy, fear of being criticized in public, feeling personally inept, fear of rejection or disapproval, difficulty expressing disagreement, being excessively devoted to work and productivity, and being preoccupied with details, rules and lists.

For children, signs of disorder occur when they are deceitful, break rules, can't sit still or wait in lines, have trouble with math, don't pay attention to details, don't listen, don't like to do homework or lose their school assignments or pencils, or speak out of turn.

Granted, one momentary feeling or behavior will not qualify you as having a DSM mental disorder; it requires clusters of them, usually for several weeks, accompanied by some level of discomfort. Nevertheless, as Freud suggested, the signs of potential pathology are everywhere.

The vast broadening of the definition of mental disorders has its skeptics, myself included, who are suspicious of the motivations of the APA and the drug companies that may view the expanding sweep of mental disorders like a lumber company lusting after a redwood forest. But unlike the environment, with its leagues of watchdogs, the medicalization of human foibles has few challengers. That's too bad: The misdiagnosis of mental illness often leaves a lasting trail in medical records open to schools, employers, insurance companies and courts.

Does it advance psychiatry to view an increasing expanse of human troubles as the expression of psychopathology rather than as part of the texture and diversity of life? Psychiatry once focused on the prevention and treatment of serious behavioral problems, of which there are plenty. But based on the metastasizing DSM, the psychiatric association appears to be caught up in a contemporary narcissistic quest for individual perfection.

The grand American experiment once was an attempt to structure our social and political institutions to create a more civil and just society. Perhaps, frustrated that we still contend with gross inequality, stinging poverty and rampant political and corporate corruption, we now embrace the perfectibility of individuals, not social institutions.

The public is being asked to swallow the view that all manner of human troubles -- from anxiety, interpersonal squabbles to misbehavior of many kinds -- be viewed not as inevitable parts of the human comedy, but as psychopathology to be treated, usually with drugs, as expugnable illnesses. The implicit ideal -- the healthy, normal and truly happy camper -- will, properly medicated, harbor no serious worries or animosities, no sadness over losses or failures, no disappointments with children or spouses, no doubts about themselves or conflicts with others, and certainly no strange ideas or behaviors. Their moods will be perfectly controlled in all circumstances, and bad hair days will be things of the past.

Is it inevitable that the rest of us, the recalcitrant, flawed resisters to the movement for individual perfection, will show up in future counts of the mentally disordered? Count me in.