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Sticky Labels


Noel O'Hare

Cold hard cash is driving campaigns to have increasing numbers of human behaviours recognised as mental disorders.

What's in a name? A lot if it's a label bestowed on you by a psychologist or psychiatrist. If you're diagnosed with a mental disorder, it could have a lasting effect on your career, your personal relationships and your credibility as a citizen. Unlike a physical ailment, which everyone accepts can be cured or controlled, a mental disorder is often seen as a permanent weakness, which may reassert itself again under stress.

Mental health professionals decide what label to put on your behaviour by consulting the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). This 943-page tome, often dubbed the "Psychiatric Bible", lists more than 350 disorders. Published by the American Psychiatric Association, it dominates the field of mental health in the way that Microsoft Windows dominates computing, but it has proved a useful classification tool, enabling psychiatrists whether they work in Wisconsin or Wellington to agree on a diagnosis. The trouble is, the number of behaviours classified as mental disorders is increasing at such rate that by the time the fifth edition comes out in 2010 most of us may be able to be labelled as mentally disordered.

As it is, the current DSM IV has come in for fierce criticism from inside and outside the psychiatric profession. One of its most trenchant critics, prominent US psychiatrist Paul McHugh, argues that it has become a grab-bag of conditions, some of which are real, but "some are dubious in the sense that they are more like the normal responses of sensitive people rather than psychiatric 'entities' and some are purely the inventions of proponents".

Take conduct disorder or oppositional defiant disorder, psychiatric labels sometimes given to the "bad behaviour" of children and teenagers. Are they real syndromes or the normal behaviour of kids who have had bad parenting or suffered abuse or trauma? If you're a shy, sensitive person, you could be branded as suffering from avoidant personality disorder (APD), while the empty-headed extrovert in the next office is seen as a model of mental fitness.

Psychiatric classifications have an aura of scientific certitude about them that is not really justified. And, unlike physical conditions, they have no proven biological basis. Brain scans won't reveal that you're an obsessive compulsive or suffer from kleptomania. Many mental disorders are social constructs that have more to do with fashion, the prejudices of the day and political pressure than scientific research.

The DSM is documented proof of that. From 1952, when it was first published, it has grown from a 119-page manual, listing only a few diagnostic categories, to the ultimate book of labels it is today. Along the way, disorders have come and gone. Remember multiple personality disorder (MPD)? After the 1976 movie Sybil, based on a supposedly true story, there were around 40,000 people in the US diagnosed with MPD. Now, as with recovered memory sexual abuse, it's generally believed to be a creation of therapists, though it's still listed as Dissociative Identity Disorder.

Before 1974, you would have been considered mentally disordered if you were homosexual. But under pressure from gay activists, the American Psychiatric Association held a vote among its members and, 5854 to 3810, the psychiatrists determined that it was not insane to be gay. The determination of physical conditions is by no means pure science, but it's hard to imagine oncologists, under pressure from smokers, voting that smoking was healthy.

And then there was self-defeating personality disorder (SDPD), which, after protests from feminists, was removed from the DSM. SDPD sufferers were said to "choose people and situations that lead to disappointment, failure or mistreatment, even when better options are clearly available". Feminists argued that it was a victim-blaming diagnosis that could be applied to battered women.

Political pressure has also been exerted to have conditions included in the DSM. In the late 1970s, Vietnam veterans campaigned to have chronic post-traumatic stress disorder (PTSD) recognised so that they could gain access to health services. "A natural alliance grew up between patients and doctors to certify the existence of the disorder; patients received the privileges of the sick, while doctors received steady employment at a time when, at the end of the conflict in South-east Asia, hospital beds were emptying," says McHugh, in his paper "How Psychiatry Lost Its Way".

Though trauma caused by war has long been recognised as a legitimate condition, studies now suggest that long-term hospital treatment often makes things worse. PTSD is now one of the most frequent diagnoses applied not only to war experiences but also to any traumatic life event. As McHugh says, because people are disturbed or even have occasional nightmares after a traumatic event, this does not mean they are mentally ill and need treatment.

For DSM V, the next edition, pressure is already mounting to include parental alienation syndrome (PAS). This is described as "the systematic denigration of one parent by the other with the intent of alienating the child against the other parent". The purpose of the alienation, apparently, is to gain or retain custody without the involvement of the father. If PAS does become accepted for inclusion in DSM, it will obviously become a legal weapon in custody battles.

Another possible inclusion in the new edition is relational disorders. If you and your partner or siblings have a rocky relationship, some psychiatrists argue, it could be that the relationship is making you mentally unwell. Some researchers also want to have compulsive shopping included. Sex addiction as a disorder has its supporters, and some definitely want Internet addiction included.

Driving the campaigns to have more and more officially recognised mental disorders is the desire for cold hard cash. If there is no DSM classification, medical insurance companies won't pay for treatment and lawyers find it harder to convince juries of the harm done to their clients. But the biggest winners from widening the definition of mental disorders are the pharmaceutical companies. "It is well known that the drug companies provide substantial funding for the American Psychiatric Association's conventions and major scientific journals and reap enormous profits from the expanding market for psychiatric medications. They also fund a substantial number of psychiatric researchers," write Herb Kutchins and Stuart A Kirk in their book Making Us Crazy: DSM - The Psychiatric Bible and the Creation of Mental Disorders.

"It is less well known that some pharmaceutical companies have contributed directly to the development of DSM. The companies have a direct financial interest in expanding the number of people who can be defined as having a mental disorder and who then can be treated with their chemical products."

Ultimately, though, the issue is not just about turning mental health into a money-spinner, but about the pathologising of everyday life. Labelling every morally or socially dubious or quirky behaviour a disorder limits our humanity. Then again, maybe I'm just a sad case of delayed oppositional defiant disorder.

Copyright 2004, Used with permission from the New Zealand Listener.

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