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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