Anti-Resilience: What Happened to Normal?
Diagnosis is a tricky word. Doctors diagnose some scientific truths: for example, a finding of a tumor and the accompanying pathology report describing cellular activity and genetic information, etc. Diagnosis is also the term used for many things for which science does not provide a distinct test – diagnosis depends in those cases on a checklist of symptoms sometimes without any corroborating biological, genetic, or chemical marker. Diagnosis of cancer is quite different from diagnosis of depression. The word diagnosis is rooted in distinguishing, knowing, and telling apart. Yet in practice, the process of determining the presence of disease differs from determining other disorders and conditions. In psychiatry, the DSM-5 broadened the definitions of many disorders significantly. In medicine, the definition of concussion also changed to cover much less traumatic head bumps. The autism spectrum likewise is huge; the narrow definition of autism from 1908 would apply to only the most severe cases. Whether acid reflux (we used to call that heartburn) or mental state, diagnoses across the board have become more inclusive, treading on the territory that was once part of the broad spectrum we called normal.
Sometimes a diagnosis is a label and affects confidence, behavior, and happiness. Other times it validates people relying on pharmaceuticals over lifestyle changes. Medicine affects society broadly; luckily, it has the power to cure disease, provide comfort, and address symptoms. But at times, medicine as an industry influences how children are raised, how coddled they are, and how much they use pharmaceuticals for new disorders (those current diagnoses for problems that in the 1970s and 80s when I was growing up would have been considered normal). Diagnosis codes are a business tool used to bill medical expenses to insurers and useful when prescribing drugs. Yet their use has expanded to the detriment of those who may do better without a diagnosis. John Cooper argues that in psychiatry words like diagnosis and disease are “best avoided”. I would argue that severity of medical conditions needs a more prominent place in diagnosis as well.
Overdiagnosis and misdiagnosis can have a negative impact (and a positive impact on pharmaceutical profits, although that aspect is not discussed here). Changing the definitions or the basket of symptoms and decreasing the number of those symptoms required for positive diagnosis, sometimes called disease creep, contribute to increasing the use of medication and decreasing resilience. Whether physical or mental, it seems to me (and perhaps it has to do with my own friends, family, culture, and norms) that there is quite a large chasm between the many people like me and the doctors, psychologists, school nurses, counselors, and trainers.
As an example, as recently as 2004, we took our daughter to the hospital and her doctor described her situation saying, “Well, she got walloped.” Now the same circumstance would subject her to a concussion protocol with more restrictions before allowing a child to return to normal activity. There is not yet consensus on concussion as more data is needed, but the current protocol is to play it safe and sit out. I worry that if the strict protocol is too strict (more research is needed) it could lead people to avoid doctors and trainers, undermining playing it safe for some people, and could bench others who may not need the full seven days symptom free.
Pathological by Sarah Fay highlights the subjectivity of psychiatric diagnosis and describes how the effect of labeling is detrimental, and even dehumanizing. She describes the comma after her name: Sarah, anorexic; Sarah, depressed; Sarah, bipolar. None were of any help to her. Once she analyzed the trends expanding the definitional criteria in the DSM-5 to include so many emotions, she realized she was misdiagnosed six times. The Loss of Sadness by Allan Horowitz and Jerome Wakefield similarly explores the effects of psychiatry, questions diagnosing people at younger ages and expanded diagnostic criteria, and notes the widespread use of antidepressants. Even sadness in the wake of a grief-causing circumstance is only tolerated for a certain amount of time, after which psychiatry steps in and labels it depression.
In 2011 in the New York Review, Marcia Angell famously acknowledged an epidemic of mental illness due to broader diagnostic criteria. She noted a thirty-five-fold increase in diagnosis of mental illness as a qualifying disability in children. Judging the mental health of a population using how many people are engaged in treatment (therapy and pharmaceutical) is to me not the proper metric. Overdiagnosis will never be found if finding the number of people afflicted is simply accomplished by adding up the total number of people diagnosed. Circular reasoning is a logical fallacy. We need more honesty about the norms and values that go into making diagnoses based on societal and professional associations’ beliefs about emotional and physical pain. The role of financial conflicts of interests should be considered too. The broadened criteria, the over-involvement of schools, the culture of mandatory reporting, and possibly fear of liability all converge. Physicians prescribing psychiatric medications are often primary care doctors filling a void rather than specialists. As I say often, societal problems call for societal answers.
Without the microscope of helicopter parents and the psycho-social-medical microscope, some things resolve without treatment. I suggest that many of those raised without the label had to get over the anxiety or cope with it. The anti-perseverance response is to pathologize, coddle, therapize, and medicate those who may have overcome the issue on their own. Narrowing diagnostic criteria could focus attention on the worst off, helping them overcome debilitating psychiatric conditions. Clumping their disorder with mild to moderate cases distracts from their needs. The broad brush of the diagnostic language reflects the funneling of experts who have trained the same way and perhaps prematurely reached consensus.
Overdiagnosis, misdiagnosis, and overprescribing pharmaceuticals affect both adults and children. One could arguably bubble wrap their child. Parents should be nurturing, responsible, and aware of (and on the lookout for) potential sicknesses, injuries, social, emotional and psychiatric problems. And it is helpful to have adults look out for children and for each other. But there may be some benefit to allowing people to hash out anticipated, typical problems on their own, to play and attend school maybe even through some light pain or discomfort (are we all expected to feel perfect every day?), to experience moderate pain (arguably at some point everyone will experience some physical and some emotional pain), and to experience sadness and nervousness. The broader diagnostic trend is concerning. Greater professional attention need not be devoted to making mountains out of molehills under the guise of safety.