Pathologizing the Human Condition

The American Psychiatric Association recently published a new version of the Diagnostic and Statistical Manual (DSM). The DSM-5 is what medical, mental health, and chemical dependency professionals use to diagnose developmental, mental health, substance abuse and dependence, learning, and personality “disorders.” Now in its 5th edition, the DSM was first published in 1952. At that time, the DSM was 129 pages containing 106 diagnoses.

Now, 61 years later, the DSM-5 consists of approximately 950 pages and roughly 375 diagnoses. The DSM-5, while researched far more than previous editions, is based on the medical model or the model of disease. Simply put, the medical model finds the causes of disease and illness and then prescribes a treatment to cure the disease or illness. This means a person has a pathology or pathogen that needs to be treated and cured.

The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:

  • Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
  • Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
  • If so, is there a “treatment” for every identified “condition?”
  • Does it mean there is a treatment that works?
  • Do you need a diagnosis to get help?

Over the years, many have been critical of this approach to mental “health” issues. Referring to mental “health” is actually a newer name as people have historically been thought to have mental “illness.” This makes more sense for people who are unfortunately compromised by severe conditions termed schizophrenia, bi-polar (manic-depressive), and severe depression and anxiety. But does this make sense for children, adolescents, and adults who are challenged with some other, and possibly less severe, aspect of their functioning and development? Do all human problems warrant a medical or mental health diagnosis? When did a weakness become a “disorder” that requires “intervention” and/or “treatment?”

To be fair, the DSM provided structure and guidelines for approaching the complicated business of determining who had a “problem” that required help. However, it seems things have gone too far. Critics of the DSM believe that this latest edition has taken the business of diagnosing to a new level, one where approximately 50% of the population can be diagnosed with something. Critics also believe that this pathology finding approach supports the continued trend of medication prescribing as the number one mode of treatment, and continued trend of increased health care costs and premiums with increased utilization of individuals who need a “diagnosis” to meet “medical necessity” to receive services. What does that mean? It means if you don’t have a diagnosis, you don’t get help. It means you have to have a problem (pathology) to get help (treatment and intervention).

Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:

  • Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
  • Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
  • Gluttony will be diagnosed as Binge Eating Disorder
  • Grief will be diagnosed as Major Depression
  • First time substance users and college partiers will get a diagnosis of Substance Use Disorder
  • Everyday Worry will be diagnosed as Generalized Anxiety Disorder

And what’s the number one treatment for all of these diagnoses? Medication. In my 20+ years of working with children, adolescent, adults, and families, I have found some simple and profound truths. First, if you talk to people about what is wrong with them and causally assign diagnostic labels to explain them, they feel badly about themselves and it plays into their low self-esteem, self-confidence, and self-worth. Next, if you help them to better understand their strengths and weaknesses, and help them to develop tools to cope with life, all of the aforementioned increases. Lastly, if you focus on their strengths, rather than their “deficits,” “disorders,” and “illness,” they become aware of neglected and unknown aspects of themselves that they can and do use to navigate life and meeting their goals.

Nothing in life that is worth anything is easy, simple, or clear. The issue of the new DSM and diagnosis is one of these. I am not saying that they both do not serve any purpose, but I am saying that they deserve very careful consideration and understanding when using either of them. I am far too aware of the need to play the game of diagnosis for insurance reimbursement and school accommodations. I am not suggesting making up diagnoses to get benefits for a client, but rather without a diagnosis, no doors – either financial, treatment, or accommodation – can open. You cannot get help if you have a significant deficit in understanding people’s facial expressions and emotions, but you can get help if you have Aspergers Disorder (now called Autistic Spectrum Disorder); you cannot get help if you have executive-functioning weaknesses and challenges, but you can get help if you have ADHD.

I ask that all mental health and medical providers, educators, administrators, adults, and parents think critically when making or accepting a diagnosis.

Ask yourself:

  • What is the purpose of making or accepting a diagnosis?
  • Does it fit my or my client’s experience?
  • How will I explain the diagnosis to my client?
  • What does this diagnosis mean to me (client)?
  • Will this diagnosis help my client (help me) achieve my goals?
  • Does the diagnosis explain a normal human emotion or condition?
  • What are all the possible helpful interventions? Can medication wait?
  • What is right with my client? What is right with me (client)?

Those of us in the field of mental health and medicine have a minimal obligation to do no harm. Further than that, we have an obligation to improve the life conditions of our clients. Our current mental health and insurance system makes this very hard, but nothing in life that is worth anything is easy.

Dan Peters, Ph.D., is co-founder of the Summit Center, which provides educational and psychological assessments, consultations, and treatment for children, their parents, and families. Summit Center works with all kids, including those who are highly gifted and those with learning disabilities.

9 replies »

  1. I lost my first wife and one daughter to suicide. Pills. Depression. Nothing in medicine is more important or more serious. It is as deadly as metastatic cancer. No professionals should be more expert or better trained. The system has to consider mental health as it would a melanoma or a case of lupus nephritis or pulmonary interstitial fibrosis. Every mental illness is significant. Every patient is valuable. We cannot consider any psychological problem as easy or trivial.

  2. Dan, Thank you for this piece. I think you make some very valid points. So much of the work we do as clinicians is to identify our clients’ strengths and help them to see themselves in a positive way. I see mostly children and teens and parents often ask me if behavior is “normal” or not. My reply is usually to say that “It’s only a problem, if it’s a problem” meaning it has to be affecting the child’s or family’s life in some problematic way. If it is, well then, we can identify tools they can use to cope and thrive. Anyhow, I have mixed feelings about all of this. I certainly want people to get help, but do not like the idea of pathologizing normal parts of being human.

  3. I am writing from the perspective of a patient.
    I suffered a traumatic experienc in my adolesence and as a result my behavior changed and i became unhappy. To this day i question whether i have reacted appropriatley to the experience or am i depressed. Does the experience itself change the chemicals in my brain or, would any reasonable person react in this way. I personally am fed up with labels as these, in my experience, have not helped my recovery at all. Sinically, from working with people on the autistic spectrum and now working in the private sector i have noticed and are unhappy about the tred for labels, and feel that at times the diagnosies can be “fashionable”. Is it right categorise people or is it better to explore thier behaviours and the roots of these behaviors. Of course funding plays a large part in diagnosies and treatment but of late i am frustrated with the “one size fits all” approach ie, in the UK at present the trend seems to be to prescrive all patients with a short course of CBT. which i agree can be helpful in the respect of people being provided with “tools” of how to recognise thier behaviors and reactions however how can it be appropriate to sa that all patients with disorder “x” (whatever the diagnosis may be will be) will be better after x ammount of sessions of CBT. I am currently nearing the end of my prescribed sessions and have been advised that after this point no further help will be available to me through the NHS which means that if i do need further help i would need to self fund this.
    I guess what i am trying to say is that the argument of cost vs appropriate tx needs to be properly looked into and tailored care needs to be prescribed (whcih would never happed ans costs need to be controlled at some level. Labels. in my opinion do not help but giving the appropriate time needed to the patient in question, without labeling them would, in my opinion, be a much better system.

  4. Agreed. After all, it’s our differences that make other people interesting.

    Furthermore, while certain differences might seem like a detriment or disorder to us, other people might not consider their unique traits to be detrimental at all.

  5. Hi Dan,

    I hope you participate in this discussion in your comments to this article, because you suggest the DSM-5 *makes* professionals like yourself diagnose ordinary behavior you otherwise wouldn’t diagnose.

    Last time I checked, the DSM-5 is a medical reference manual, just like the ICD-9 and ICD-10. Those reference books don’t make a doc diagnose cancer, and more than the DSM-5 can make a psychologist like yourself classify what you’d consider “everyday worry” as GAD.

    I find articles like this sadly shallow — disrespectful of the years of work and hundreds of mental health professionals’ time and efforts that went into this revision. How about a nuanced discussion about some of these changes, instead of a black-and-white, the sky-is-falling indictment of a medical reference manual?

    I’d look forward to such a nuanced and reasoned discussion.

  6. It would be interesting to correlate the number of relationships with Big Pharma among the compilers of this edition. Pharma is the most insidious and effective pathologizer of all. Except for real diseases like infection, for which there are no new antibiotics because they are not profitable enough.

    I wonder if the members of the compiling committee were required to submit this information.

  7. A well thought out and well written essay. I am glad that Mr. Peters is thinking about things like this.

    I don’t think we need to label everything and I think we need to accept that some people are just “built different”.

  8. So, this and that “disorder.” What, then, constitutes “order”? (Ahhhh.h.h… there’s no billing code for that.)

    Does the absence of a psych dx mean that you DON’T EXIST?

    Q: “What’s the definition of a well person?”
    A: “A patient who not not been worked up adequately.”

    Thomas Szasz — before he went all Ayn Randian mentally ill — once jibed about a dx code resulting in a px code for a “Humanectomy.”

    He also cogently observed that “The Law of the jungle is ‘eat or be eaten.’ The law of civilization is ‘define or be defined.”