Diagnosis is a dangerous thing. Think deep or taste not the Asclepian spring Or “En maladie il n’y a plus du devoir”
It’s a curious phenomenon – maybe – that people these days often work hard to get diagnosed with a range of mental disorders. Those burdened by longevity in the mental health business wearily comment on this significant cultural change and the reversal of roles or positions that it has brought about. Where once clinical work consisted largely (if ineffectually) of trying to convince reluctant patients that they in fact had this or that disorder, over the past decade or two well-briefed patients may, having cajoled their GP into referring them on, set about trying to convince the specialist clinician in front of them that they have a condition warranting support and intervention from a growing cluster of particular psychological or psychiatric disorders. Currently, these tend to be Asperger’s syndrome (AS), autistic spectrum disorder (ASD), adult attention deficit hyperactivity disorder (ADHD), borderline or emotionally unstable personality disorder (BPD/EUPD), bi-polar disorder (BPAD) and, less often, dissociative identity disorder (DID) - the UK version of what in the USA is called multiple personality disorder - but others will certainly join this cohort in time. On the other side of the purely theoretical, dualistic cusp are constructs which committed subscribers generally see as essentially physical, such as chronic fatigue syndrome, the preferred name for what used to be ME, which is also sometimes called systemic exertion intolerance disease, fibromyalgia and so on.
Old timers will argue that this is partly an unintended or unforeseen consequence of reducing stigma, in that patients will resist, often over decades of treatment and personal disaster, stigma-rich diagnoses such as paranoid schizophrenia or psychopathic personality disorder, but covet a diagnosis of the increasingly stigma-lite disorders listed above. Trained on Illich, Szasz, Laing, Foucault and other big beasts of the psycho-jungle, now unregarded and almost certainly extinct, they also see this trend as a ruse of the market, generating new needs in order to devise new products.
Relative newcomers, whether providers or consumers, will instead contend that more enlightened, progressive attitudes have allowed once hidden suffering to be revealed and that sufferers in silence should be accorded the recognition and treatment which it is their right to have. The vested interests which very quickly coalesce around whatever might be the latest brand of disorder initially proffer treatment, whether psychological or pharmacological, and support (this provided by agencies lower down the food-chain) but then rapidly call for earlier intervention and increased state investment to finance it. Any opposition to this current of product-development is portrayed as callous and in favour of suffering which, of course, other than in a world dazzled by idealised fantasy, can be a respectable and defensible to position to take.
Illness essentially consists of a fact plus a judgement. Diagnosis is what doctors (mainly but not exclusively) do and is not a universal truth. Arguments about whether or not a psychological condition is actually a myth (see Thomas Szasz etc) or whether the seemingly coveted ones with a physical or material ring are real, lead away from this essence and set up a false polarity. The fact of mental health conditions may be directly, physically observable through EEG or MRI scanning or blood tests, as in the case of dementia, alcohol-related encephalopathy or temporal lobe epilepsy, for example, or through observation of a potential patient’s behaviour and demeanour; it may be inferred from what he or she, or a reliable informant, reports; or it may be deduced from an accurately collated history of events and so on. The absence of objective evidence of brain or chemical aberration does not make the condition myth because a construct can have meaningful validity in the absence of such evidence and also because it is certain that new abnormalities (determined by value judgements, of course) will soon be uncovered (or coined, strictly speaking) when our still crude understanding of the dark brain and its influence on mind is sharpened by far more sophisticated tools and methods of detection. Thus Gary Greenberg’s contention in “The Book of Woe: the DSM and the Unmaking of Psychiatry” that the developing, elastic concepts of ASD, ADHD and BPAD have no validity because there is no evidence of chemical imbalance to support them misses two key points: first, that a construct can have validity in its broadest sense without such evidence and, secondly, that even if unusual chemical features were to be found, it doesn’t follow necessarily from this that there is a disorder present because whether or not they should be considered an imbalance and pathological still requires an albeit soft value judgement.
The decision as to whether phenomena should be classified as illness is always socially determined. A common argument in the mental health field used to be that, because the incidence of schizophrenia is roughly the same around the world (about 1 in 100 people), other than in the USA and Russia, this somehow demonstrates that it is incontrovertibly an illness – for all time, as it were. However, the normative dye can’t be rinsed out of the recognition of phenomena as illness altogether since it is theoretically possible to imagine a society where the more or less universal symptoms of schizophrenia are not considered to be an illness but a sign of great spirituality, imagination, heightened awareness of the unconscious, and so on; or a signpost to work which needs to be done by the individual rather than pathology which must be extinguished.
This can been seen most clearly in conditions which are placed on a spectrum instead of being seen as discrete entities, perhaps with some blurred edges. This moves the decision about whether phenomena should be deemed abnormal from the machine or, increasingly, the computer to an array of medical and lay “experts” and agencies who have some kind of interest in where the line on the spectrum should be drawn. This can be seen clearly in autism spectrum disorder where those who in a different time or culture would be seen as eccentric, quirky or prickly are now said to be “suffering from” high-functioning autism; but the moving line can also be seen in certain kinds of personality disorder and even bi-polar disorder which has developed out of manic depression, once a discrete and clinically unmistakeable condition which has morphed into an elastic and subjective one.
The fluidity of diagnosis and the aetiology which pushes conditions forward provide an opportunity for political allegiances to be demonstrated. Those who challenge therapeutic expansionism tend to be seen by leftist partisans as denying the illness-inducing effects of callous and reactionary policies while those who are differently aligned view them as dupes of a moribund capitalist system which scans the horizon for potential patient-consumers to perpetuate the project. Thus, curiously, those who attribute much of mental illness to the deleterious effects of late-stage capitalism are, in promoting an illness culture, actually doing the work of late-stage capitalism which is indifferent to where it gets its customers from.
Patienthood in this part of the diagnostic lexicon brings many advantages to those on whom it is conferred: for example, exemption (from work), entitlement (to financial benefits), dispensation (leading to special adjustments at work, for example), exculpation (from punishment for wrong-doing), legitimisation (of behaviours which might otherwise attract blame or disapproval), vindication (when others were sceptical or unsupportive in the past), explanation (for troubling feelings or experiences), a sense of belonging and solidarity with similar others, a distinct identity and role with quite narrow requirements, reassurance, relief, consonance (being in tune with unrevealed wishes or impulses), and so on. Thus, it is sweet to be sick; lonely and arduous to be well.
The politics of pathology determine the scope and elasticity of psychological disorder. These are mediated through classifications, such as DSM-5 in the USA and ICD10 (the WHO system used in the UK), guidelines (produced by the National Institute for Health and Care Excellence or NICE), research and especially the market, in both its economic and clinical form, which must create or fuel problems (for example, dissatisfaction, disappointment, a sense of need, trouble or wanting) so that it can devise, promote and sell solutions. The removal of homosexuality as a disorder from the American classification in 1973 and the more recent debate about whether and the way in which bereavement should be included in DSM-5 highlight the ethico-political dimension of the judgement about whether phenomena or facts should be deemed to be pathological.
Satisfaction is to the market what kryptonite was to Superman. As material satisfaction (in the West, at any rate) or saturation approach and shopping becomes more a pastime competing with many others and less a necessity, the market seeks to industrialise the mind and problematize its imperfections. For the consumer, an appetite for things is being naturally replaced by a hunger for experience, attention and validation. A by-product of this process is the removal of ought (see Lipovetsky: “Le Crepuscule du Devoir”) from illness with the result that how one copes with and reacts to designated illness is not limited or influenced by socially agreed standards or expectations but has become largely a matter for self-definition or individual choice. Once healthcare becomes shopping (with no credit card maximum), there are no limits – other than those the state and employers try to impose, for example by squeezing those on sickness and disability benefits or, in the case of the latter, by hauling back absentees for ritual and generally ineffective reviews.
The dissolution of age-old restrictions on responses to phenomena construed as illness has left a vacuum in which the subjectivity (a complicated amalgam of personality, brain, heredity and cultural determinants) of the individual sufferer has few limits: Stoicism (Epictetus: “a Stoic is one who is sick and yet happy, in peril and yet happy, dying and yet happy”) has given way to selfism: “my personal tolerance of pain, discomfort, strangeness or tiredness is what should determine the fact and scope of treatment”.
Diagnosis is no longer an unpleasant event in the unequal struggle to be well-enough, independent and self-reliant. Instead, it has become a badge which determines identity, another stripe which confers deservingness and worth. It is an amulet which converts questions about the validity or usefulness of the construct which it declares into an unwarranted attack, and protects the wearer against unwanted demands and culpability. This is the age of nosogenic disorders in which constructs create patients – and of the coming paradox that if you are not ill, you are not well.