Does the DSM-5 medicalize normal behavior?

by John Gever

Just about everyone catches colds, and just about everyone who gets one is able to go to work and cook their meals, and they nearly always recover within a few days whether or not they take anything for it. That’s normal.

So, is the advice to take aspirin “medicalizing normal behavior”? Are drug companies that market decongestants and fever reducers “medicalizing normal behavior”?

The answer is yes, if you accept the logic offered by some critics of DSM-5, the upcoming revision of the Diagnostic and Statistical Manual of Mental Diseases.

Recently, the Journal of Mental Health provided a platform to these critics, who include the journal’s executive editor, Til Wykes of King’s College in London.

In an editorial introducing this special edition of the journal, Wykes and a colleague, Felicity Callard, lamented that the changes in diagnostic criteria proposed in DSM-5 “imply a more inclusive system of diagnoses where the pool of ‘normality’ shrinks to a mere puddle.”

A press release from the journal also argued that “technically, with the classification of so many new disorders, we will all have disorders.”

Well, technically, this is utterly false. I know from having covered the DSM revision process for the last several years that, in fact, the new diagnoses are quite narrowly defined.

For example, temper dysregulation disorder with dysphoria — derided in a recent Reuters lede as a diagnosis for “toddler tantrums” — includes 12 criteria that must all be met (including an age of at least six, ruling out toddlers entirely). It’s patently obvious that relatively few children are going to get this diagnosis at all, and most of them would have received one anyway (childhood bipolar disorder has long been a favorite).

That’s not the main point, though. The DSM-5 critics essentially argue that it’s important for most people be labeled as” normal” in order to protect them from drug companies and their physician-stooges.

They’re wrong about that, too.

It’s true that drug companies often do little to discourage off-label use of psychiatric drugs and sometimes encourage it. It’s also true that many doctors throw medications at patients who might do better with other treatments or no treatments. (That’s true for many somatic conditions too, let’s not forget.)

But not many people are plucked off the street to have psychiatric labels stuck on them. Most often, people get a DSM diagnosis because they were distressed enough to see a doctor.

That’s the key word — distressed. These are people who aren’t happy and who want to feel better. Or their children are unhappy and having trouble at school. Either way, they’re seeking help.

You might argue that life isn’t a bowl of cherries, and I’d agree with you. But then I’d point out that being somatically unhealthy is normal too.

Allergies, acne, high cholesterol, high blood pressure, back problems, bowel problems, bladder problems, warts, heartburn, achy joints, achy heads — really, how many of us have none of these?

So why, when it comes to mental health, should we have a different expectation? In fact, most of us have some type of distress at least some of the time, and maybe a psychiatric evaluation can help.

Isn’t that what medical professionals are supposed to do — evaluate and provide help? Even when they don’t know exactly what’s going to help?

Instead, Wykes and the other critics think it’s best to keep patients away, their distress notwithstanding. Maybe that Geico commercial now airing isn’t such a parody.

Seriously, we should wonder why some psychiatrists hate themselves so much.

John Gever is a senior medical editor at MedPage Today and blogs at In Other Words, the MedPage Today staff blog.

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  • David Behar, MD,EJD

    Anxiety is a disorder of fear without a danger. Depression is a disorder of sadness without any loss.

    We need a cool name like those for anger without a frustration, other than, temper dysregulation disorder with dysphoria.

    Get out your ancient Greek dictionary and start digging.

  • madoc

    The DSM doesn’t help patients. Throw the DSM5 in the trash can.

  • HJ

    I don’t agree that having a viral infection is normal. It is a disease state. And having a cold is not a behavior.

  • Katherine at Postpartum Progress


  • A

    This is a very defensive article. For ex, why does it have to take it to the level of “psychiatrists hating themselves” just because they have a different opinion?

    I think the problem is that there are ranges of psychological distress. (precisely the issue a dimensional model tries to address) Yet, if someone just needs help getting through a rough time goes to a psychotherapist, if they don’t get an actual diagnosis many insurnace companies won’t pay for their therapy. That’s a problem. It pathologizes normal distress, and keeps people from getting help. Not the other way around.

    Just because someone needs professional help with psychological issues doesn’t mean they need a diagnosis slapped on them. The human condition isn’t as clear cut as say, a virus or a broken bone.

  • Jenny Reiswig

    Commenter A: “Just because someone needs professional help with psychological issues doesn’t mean they need a diagnosis slapped on them.”
    It does mean they need a diagnosis if they expect to have that help somehow paid for by a third party. If the patient is on the hook for the bill then sure, psych* services become like cosmetic procedures – entirely elective. But there’s that word “need” in your comment.

  • BobBapaso

    DSM-I wasn’t too bad, because it pretty much just listed the politically correct diseases of the day. Then a disease came complete with a theory of cause which suggested approaches to treatment and provided criteria to test the theory. Today, “disorders” masquerade as diseases but are really what used to be caused syndromes. They are collections of symptoms with no suggestion of why they are sometimes found together. We could go back to an honest system of diagnosis if we could just get insurance companies to pay for syndromes as well as diseases.

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