Saving Normal CHAPTER 1. What’s Normal and What’s Not?

← Saving Normal An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life

Saving Normal CHAPTER 1. What’s Normal and What’s Not?

Author: Allen Frances Publisher: New York, NY: HarperCollins. Publish Date: 2013 Review Date: 2023-6-7 Status:📚

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You might expect normal to be an approachable sort of word, confident in its popularity, safe in its preponderance over abnormal. Defining normal should be easy, and being normal should be a modest ambition. Not so. Normal has been badly besieged and is already sadly diminished. Dictionaries can’t provide a satisfying definition; philosophers argue over its meaning; statisticians and psychologists measure it endlessly but fail to capture its essence; sociologists doubt its universality; psychoanalysts doubt its existence; and doctors of the mind and body are busily nipping away at its borders.

despite all of its acknowledged wonders, modern medical science has never provided a workable definition of “health” or “illness”—in either the physical or the mental realms. Many have tried and all have failed. Take, for example, the World Health Organization’s definition5: “Health is a state of complete physical, mental, and social well-being and not merely the absence of infirmity.” Who among us would dare claim health if it requires meeting this impossibly high standard? Health loses value as a concept when it is so unobtainable that everyone is at least partly sick. The definition also exudes culture and context-sensitive value judgments. Who gets to define what is “complete” physical, mental, and social well-being? Is someone sick because his body aches from hard work or he feels sad after a disappointment or is in a family feud? And are the poor inherently sicker because they have fewer resources to achieve the complete well-being required of “health”?

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ABIM Foundation, “Choosing Wisely”; http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx (accessed August 18, 2012).

More realistic modern definitions of health focus not on the perfectibility of life, but on the lack of definable disease. This is better, but there is no bright-line definition of physical disease and certainly nothing that works across time, place, and culture. How do we decide what is normal in continuum situations like blood pressure, or cholesterol, or blood sugar, or bone density? Is a slow-growing prostate cancer in an old person best diagnosed and treated aggressively as disease—or left alone because neglect may be much less dangerous than treatment? Is the average expectable forgetting that occurs in old age the disease of dementia or the unavoidable degenerative destiny of a brain grown old? Is a very short child just short or in need of hormone injections?6

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“Neuron,”http://en.wikipedia.org/wiki/Neuron#Neurons_in_the_brain (accessed August 18, 2012).

Why No Lab Tests to Define Normal in Psychiatry

The human brain is by far the most complicated thing in the known universe. The brain has 100 billion neurons, each of which is connected to 1,000 other neurons—making for a grand total of 100 trillion synaptic connections. Every second, an average of 1,000 signals cross each of these synapses; each signal is modulated by 1,500 proteins and mediated by one or more of dozens of neurotransmitters.7 Brain development is even more improbable—a miracle of intricately choreographed sequential nerve cell migration. Each nerve has to somehow find just its right spot and make just the right connections. Given all the many steps involved and all the possible things that can go wrong, you might want to place your bet on Murphy’s Law and chaos theory—the odds seem to be stacked against normal brain functioning. The weird and wonderful thing is that we work as well as we do—the improbable result of exquisitely wrought DNA engineering that has to accomplish trillions and trillions of steps. But any super-complicated system will have its occasional chaotic glitches. Things can and do go wrong in many different ways to produce each disease, which makes it hard for medical science to take giant steps.

The two most exciting advances in the entire history of biology are unraveling the workings of the human brain and breaking the genetic code. No one could have predicted that we would have come so far and so fast. But there has also been a great disappointment. Although we have learned a great deal about brain functioning, we have not yet figured out ways of translating basic science into clinical psychiatry. The powerful new tools of molecular biology, genetics, and imaging have not yet led to laboratory tests for dementia or depression or schizophrenia or bipolar or obsessive-compulsive disorder or for any other mental disorders. The expectation that there would be a simple gene or neurotransmitter or circuitry explanation for any mental disorder has turned out to be naive and illusory.

We still do not have a single laboratory test in psychiatry. Because there is always more variability in the results within the mental disorder category than between it and normal or other mental disorders, none of the promising biological findings has ever qualified as a diagnostic test. The brain has provided us no low-hanging fruit—thousands of studies on hundreds of putative biological markers have so far come up empty. Why the gaping disconnect—so much knowledge and so little practical utility? As Roger Sperry put it in his Nobel Prize in Medicine acceptance speech: “The more we learn, the more we recognize the unique complexity of any one individual intellect, the stronger the conclusion becomes that the individuality inherent in our brain networks makes that of fingerprints or facial features gross and simple by comparison.”8 Teasing out the heterogeneous underlying mechanisms of mental disorder will be the work of lifetimes. There will not be one pathway to schizophrenia; there may be dozens, perhaps hundreds or thousands.

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“Roger W. Sperry—Nobel Lecture: Some Effects of Disconnecting the Cerebral Hemispheres.” Nobelprize.org. 26 Sep 2012; http://www.nobelprize.org/nobel_prizes/medicine/laureates/1981/sperry-lecture.htm.

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The brain reveals its secrets only slowly and in very small packages. Every exciting finding turns out to be a tease—providing no simple answers, rarely replicating fully in the next study, uncovering more heterogeneous complexity than it explains. To use a baseball analogy—there are no grand slams in this work and no walks, just plenty of strikeouts and at best the occasional single. And this will be a very slow and retail slog, not any one great leap forward. We will not have biological markers to set the boundary between normal and mental disorder until we understand the multitudinous mechanisms causing the different forms of psychopathology. And there won’t be a Newton or an Einstein or a Darwin to provide a grand unifying biological theory of normality and mental disorder—just patient scientists each working for decades to elucidate one very tiny piece of an enormous, trillion-piece jigsaw puzzle. Causes for mental disorder, as they are discovered, will (as with breast cancer) explain only a small percentage of the cases. The first real step in this advance will be laboratory tests for Alzheimer’s dementia, probably ready to come online sometime in the next

The absence of biological tests is a huge disadvantage for psychiatry. It means that all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change. It is like having to diagnose pneumonia without having any tests for the viruses or bacteria that cause the various types of lung infection.

Can Psychology Ride to the Rescue?

Sadly no. We can do psychological tests on people till they are bleary- eyed and blue in the face and still not be much further along in setting the boundary between who is normal and who is not. The limitation of almost all tests used by psychologists is that the distribution of their results follows our old friend—the bell-shaped normal curve. The test can tell us with remarkable precision just where a given person stands with respect to his comparison group, and knowing someone’s standard deviation position relative to the mean often has considerable predictive value. But the testing doesn’t tell us where to set the cutoffs for what is normal. That is determined by context, not by test score.

Take IQ testing. Two standard deviations below the mean of 100 put you at 70 and predicts the likelihood of school and life difficulties. Two standard deviations above normal put you at 130 and predicts academic and career success. But there isn’t any reason to think that having a IQ of 70 is really different from having one of 71 or even 75.9 There is a 5-point error of measurement in the test, many factors may have interfered with optimal test taking, and some people perform in life much better or worse than you might expect just from their IQ.

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N. J. Macintosh, I.Q. and Human Intelligence (New York: Oxford UniversityPress, 1998).

Selecting 70 as the unique cutoff for clearly disordered intellectual ability is purely an arbitrary convenience that has no particular significance other than that it selects for the lowest 2.5 percent of the population. These individuals are likely to qualify for special services and dispensations that are denied their near and almost identical neighbors. But there is nothing sacred about the two standard deviations below 100 cutoff at IQ 70—it doesn’t have a real world meaning. Slightly higher or slightly lower cutoffs would make equal or more sense, depending on the situation. If more resources are available, services should be offered to those with higher IQs than 70. In some environments, people with an IQ of 70 do just fine. And who says that two standard deviations should be the cutoff? Why not one or three or one and a half? The choice is always arbitrary and driven by context, not statistics.

This gets lost in translation. A recent galling example followed the Supreme Court ruling that it is unconstitutional to execute anyone who is suffering from mental retardation. Life versus death now depends on the silly, artificial nondistinction of having an IQ of 70, rather than 71.10

What would happen if we applied the two SD cutoff (2.5 percent) to psychiatry and suddenly required that people be that far removed from the golden mean of mental health before they could merit a diagnosis of mental disorder. Psychiatrists and other mental health workers would mostly be put out of business and have to collect unemployment insurance. One hundred years ago, psychiatry was limited to the very severely ill housed in hospitals, and very few people were employed caring for them. We have since worked our way up the bell curve much closer to the mean—so that 20 to 25 percent are currently considered mentally disordered, and we have more than half a million people caring for them. Using the psychological test paradigm, we can compare people very precisely to one another but have no way to decide whether to draw the line between normal and abnormal at 2.5 percent or 25 percent of the population.

“Mental disorder” and “normality” are both extremely protean concepts—each so amorphous, heterogeneous, and changeable in shape that we can never establish fixed boundaries between them. The definitions of mental disorder generally require the presence of distress, disability, dysfunction, dyscontrol, and/or disadvantage. This sounds better as alliteration than it works as operational guide. How much distress, disability, dysfunction, dyscontrol, and disadvantage must there be, and of what kind?13 I have reviewed dozens of definitions of mental disorder (and have written one myself in DSM-IV) and find none of them the slightest bit helpful either in determining which conditions should be considered mental disorders and which not, or in deciding who is sick and who is not.14–18

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Jerome Wakefield, “The concept of mental disorder: On the boundary between biological facts and social values,” American Psychologist, 47 (1992): 373–88.
R. M. Bergner, “What is psychopathology? And so what?” Clin Psychol Sci Pract. 4 (1997): 235–48.
D. F. Klein, “Harmful dysfunction, disorder, disease, illness, and evolution,” J Abnorm Psychol 108 (1999): 421–29.
T. A. Widiger and L. M. Sankis, “Adult psychopathology: issues and controversies,” Annu Rev Psychol 51 (2000): 377–404

Not having a useful definition of mental disorder creates a gaping hole at the center of psychiatric classification, resulting in two unanswered conundrums: how to decide which disorders to include in the diagnostic manual and how to decide whether a given individual has a mental disorder. Binge eating was once considered a sin; should it now be a psychiatric disorder? Is the forgetting of old age an illness or just old age? Is having sex with a teenager just a crime or also a sign of craziness? And in evaluating any given person, we lack a general definition of mental disorder to help us decide whether he is normal or a patient, mad or bad.19, 20

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J. C. Wakefield and M. B. First, “Clarifying the distinction between disorder and nondisorder: confronting the overdiagnosis (false-positives) problem in DSM-V,” In Advancing DSM. Dilemmas in Psychiatric Diagnosis, ed. K. A. Phillips, M. B. First, H. A. Pincus (Washington, D.C.: American Psychiatric Association, 2003), 23–55.
Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (Washington, D.C.: American Psychiatric Press, 2000).

The mental disorders included in DSM-5 have not gained their official status through any rational process of elimination. They made it into the system and have survived because of practical necessity, historical accident, gradual accretion, precedent, and inertia—not because they met some independent set of abstract and universal definitional criteria.21, 22 No surprise then that the DSM disorders are something of a hodgepodge, not internally consistent or mutually exclusive. Some mental disorders describe short-term states, others lifelong personality; some reflect inner misery, others bad behavior; some represent problems rarely or never seen in normals, others are just slight accentuations of the everyday; some reflect too little self-control, others too much; some are intrinsic to the person, others are culturally determined; some begin early in infancy, others emerge only late in life; some affect thought, others emotions, behaviors, interpersonal relations; some seem more biological, others more psychological or social; some are supported by thousands of research studies, others by a mere handful; some may clearly belong in DSM, others could have been left out and perhaps should be eliminated; some are clearly defined, others not; and there are complex permutations of all of these possible differences.

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R. L. Spitzer and J. B. W. Williams, “The definition and diagnosis of mental disorder,” In Deviance and Mental Illness, ed. W. R. Gove (Beverly Hills, CA: Sage, 1982), 15–32.
D. J. Stein and others, “What is a mental/psychiatric disorder? From DSM-IV to DSM-V.” Psychol Med 40 (2010): 1759–65.

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I sometimes joke that the only way to define mental disorder is “that which clinicians treat; researchers research; educators teach; and insurance companies pay for.” Unfortunately, this practical “definition” is elastic, tautological, and potentially self-serving—following practice habits rather than guiding them. The greater the number of mental health clinicians, the greater the number of life conditions that work their way into becoming disorders. Only six disorders were listed in the initial census of mental patients in the mid-nineteenth century; now there are close to two hundred. Society has a seemingly insatiable capacity (even hunger) to accept and endorse newly minted mental disorders that help to define and explain away its emerging concerns.

Are Mental Disorders Diseases, Myths, or Something Else?

Some radical critics of psychiatry have seized on its definitional ambiguities to argue that the profession should not exist at all. They take the difficulty in finding a clear definition of mental disorder as evidence that the concept has no useful meaning—if mental disorders are not anatomically defined medical diseases, they must be “myths,” and there is no real need to bother diagnosing them. This position is most appealing to libertarians concerned with preserving patient freedom of choice from what they perceive to be the enslaving snares of psychiatry. “Saving normal” is taken by them to its logical extreme—the extremely illogical position that everyone is normal.

This shibboleth can be believed only by armchair theorists with no real life experience in having, living with, or treating mental illness. However difficult to define, psychiatric disorder is an all-too-painful reality for those who suffer from it and for those who care about them.23 Saving normal, as I use the term, is not meant to deny the value of psychiatric diagnosis and treatment. Rather, it is an effort to keep psychiatry doing what it does well within its appropriate limits. It is equally dangerous at either extreme—to have either an expanding concept of mental disorder that eliminates normal or to have an expanding concept of normal that eliminates mental disorder.

The best way to understand the essence of mental disorder—what it is and what it is not—is to compare the balls and strikes calls of three different umpires. Most of epistemology boils down to their competing opinions on how well we can ever apprehend reality.

Umpire One: “There are balls and there are strikes and I call them as they are.”

Umpire Two: “There are balls and there are strikes and I call them as I see them.”

Umpire Three: “There are no balls and there are no strikes until I call them.”

Umpire One believes that mental disorders are real “diseases”; Umpire Three that they are fanciful “myths”; Umpire Two that they are something in between—useful constructs that provide no more (but no less) than a best current guess on how to sort psychiatric distress.

Umpire One has great faith in our ability to detect the true essence of things. For him, mental disorders will soon reveal their secrets through scientific study. This optimism was shared by most biological psychiatrists until about fifteen years ago but, except for a few diehards, is now rapidly fading away. Billions of research dollars have failed to produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause.24, 25, 26 Dozens of different candidate genes have been “found,” but in follow-up studies each turned out to be fool’s gold. Mental disorders are too heterogeneous in presentation and in causality to be considered simple diseases; instead each of our currently defined disorders will eventually turn out to be many different diseases. For now at least, Umpire One has been called out on strikes.27, 28, 29

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J. C. Wakefield, “The myth of DSM’s invention of new categories of disorder: Hout’s diagnostic discontinuity thesis disconfirmed,” Behav Res Ther 39 (2001): 575–624.
S. A. Kirk, ed., Mental Disorders in the Social Environment: Critical Perspectives (New York: Columbia University Press, 2005).
Jeffrey A. Schaler and others, “Mental Health and the Law,” Cato Unbound, August 12, 2012 edition; http://www.cato-unbound.org/issues/august-2012-mental-health-and-the-law.
James Phillips and others, “The Six Most Essential Questions in Psychiatric Diagnosis,” Philosophy, Ethics and Humanities in Medicine, February 2012; http://www.peh-med.com/content/7/1/3.
D. S. Charney and others, “Neuroscience research agenda to guide development of a pathophysiologically based classification system,” in A Research Agenda for DSM-V, eds. D. J. Kupfer, M. B. First, D. A. Regier (Washington, D.C.: American Psychiatric Association, 2005), 31–84.
S. Hyman, “The diagnosis of mental disorders: the problem of reification,” Annu Rev Clin Psychol. 6 (2010):155–79.

Umpire Three presents just the opposite view—the skeptical and solipsistic doubt that man can ever catch protean reality by the tail and know things as they truly are. He would argue that mental disorders are no more than arbitrary and sometimes noxious “myths” that unfairly restrict the freedom of choice of psychiatric patients. He worries about the slippery slope that eventually could be extended to other vulnerable groups.30 Indeed, there is reason for this concern—psychiatric diagnosis is now being abused for preventive detention of rapists in the United States and peasants complaining about corruption in China and previously was an excuse to hospitalize political dissidents in the Soviet Union.

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T. R. Insel, “Translating scientific opportunity into public health impact. A strategic plan for research on mental illness,” Arch Gen Psychiatry 66 (2009): 128–33.

It is of course imperative that we protect against the misuse of psychiatry in the service of legal or political masters—but Umpire Three far overstates his case. Mental disorders are not myths. Though not a discrete “disease entity” (like, say, a brain tumor or a stroke), schizophrenia produces profound and prolonged “dis-ease”—that is, distress and incapacity. The patterns of its presentation are clearly recognizable, can be reliably diagnosed, run in families, have brain imaging correlates, predict course, and respond to specific treatments. Schizophrenia is real enough and no psychiatric invention for those who suffer from it and for their loved ones.

Umpire Two has the firmest grasp on elusive reality, paradoxically because he understands and accepts that we can know it only partially. Of course, reality is “protean”—constantly changing shape and hard to hold. No doubt there is an enormous gap between things as they really are and things as we perceive them—and not just in psychiatry. Only 4 percent of our known universe can be directly detected by our senses—the rest of its energy and matter remaining “dark” to us. The quantum world is so weirdly discordant with our own that even the physicists who can mathematically predict its every characteristic cannot find an intuitive way to relate to it. And how can light manage to be a wave that suddenly turns into a particle just when we choose to look at it a certain way.

Elusive reality does not discourage Umpire Two. We don’t have to fully perceive or understand the underlying nature of our world to negotiate it well. Our senses and reasoning powers evolved as they did because they work just fine in the everyday, nonphilosophical business of survival. Mental constructs of reality are imperfect, but indispensable, ways to organize the otherwise bewildering phenomena of the world.

Umpire Two “calls them as he sees them.” Mental disorders are not real diseases as Umpire One might wish; but neither are they the dangerous myths feared by Umpire Three. Instead he follows a down-to-earth brand of utilitarian pragmatism. His umpire’s eye is fixed on what works best—not distracted by biological reductionism or rationalist doubt. He accepts that we are constantly constructing perceptions and finding temporary meanings that are useful, but never completely accurate. Our classification of mental disorders is no more than a collection of fallible and limited constructs that seeks but never finds the truth—but this remains our best current way of communicating about, treating, and researching mental disorders.

Schizophrenia is a useful construct—not myth, not disease. It is a description of a particular set of psychiatric problems, not an explanation of their cause. Someday we will have a much more accurate understanding and more precise ways of describing these same problems. But for now, schizophrenia is very valuable in our day-to-day work. And so are the other DSM disorders. It is good to know and use the DSM definitions, but not to reify or worship them.31,32

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M. B. First and A. J. Frances, “Issues for DSM-V: unintended consequences of small changes: the case of paraphilias,” Am J Psychiatry 165 (2008): 1240–41.
A. J. Frances and others, “DSM-IV: work in progress,” Am J Psychiatry 147 (1990): 1439–48.

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What about the potentially distorting lens of culture? Do mental disorders present the same way everywhere or does each culture need its own diagnostic system? The answer seems to be that one size usually fits almost all. Although “normal” behavior is variable across cultures, the specific mental disorders are pretty uniform. Dementia, psychosis, mania, depression, panic attacks, anxiety, obsessive-compulsive disorder, and the personality disorders have been described in all past ages and in all places and are found today in epidemiological studies wherever in the world these are conducted. When rates of disorder differ (e.g., blacks being diagnosed more often with schizophrenia in the United States), it is because of bias or cultural blind spots in the raters, not real differences in the patients they are rating.33

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A. Barnes, “Race, schizophrenia, and admission to state psychiatric hospitals,” Administration and Policy in Mental Health 31 (2004): 241–52.

There are two diagnostic systems in current, overlapping use around the world—DSM-5 (soon to be translated into about twenty-two languages) and ICD-10, developed by the World Health Organization (translated into forty-two languages).34 DSM-5 and ICD-10 are really very similar; which is not surprising, since they are closely related sibs. Both are no more than minor modifications of the same parent (DSM-III) and were prepared at the same time and with some efforts to achieve harmony. As with sibs, there is a rivalry between systems. The DSMs have so far been more influential, but it will be several years before we can judge whether DSM-5 or ICD-11 (planned for publication around 2016) will win the next round of the competition. For now, the relative merits of DSM and ICD are pretty obvious—DSM is used much more often in research; they are about equal for clinical work in the developed countries; and ICD works better when a simpler system is needed in the developing world.35

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ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines (Geneva: World Health Organisation, 1992).
A. Frances, “Integrating DSM-5 and ICD 11,” Psychiatric Times, November 2009.

The more fascinating question is why both diagnostic systems have gained such universal applicability across all the races and cultures of the world. Clearly we humans are more alike than we are different, resembling one another closely in the things that count toward defining normal and mental disorder.

There are no genetically caused racial differences in mental disorder. How come there is such uniformity? Compared to other species, humans have a remarkably homogeneous gene pool. Genetic and geologic evidence converge on the theory that there was a catastrophic die-off of humans about 70,000 years ago caused by a giant volcanic super eruption in what is now Indonesia.36 Our species was almost wiped out by the protracted climate change, and most of us are the closely related descendants of the few thousand breeding pairs who survived. Racial differences, for all the trouble they cause, are literally skin deep, of recent vintage, and result in relatively few differences in how medical and mental problems express themselves.

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Richard Dawkins, The Ancestor’s Tale: A Pilgrimage to the Dawn of Evolution (Boston: Houghton Mifflin, 2004), 416.

Culture plays a much bigger role but influences only the surface presentations. Brief psychotic disorders and physical symptom presentations are much more common in poorer parts of the world and anorexia nervosa and attention deficit in the richer. In diagnosing and treating, it is crucial to be sensitive to cultural differences, but they are not so great as to require different diagnostic systems for different parts of the world. Across the board, humans are alike enough genetically and culturally that one diagnostic system (either DSM or ICD) is elastic enough to fit all the possibilities.

The bad news that we can’t develop a useful definition for the general concept “mental disorder” is balanced by the very good news that we can quite easily define each one of the specific mental disorders. The method, introduced by DSM-III in 1980, is simple and effective. The description of each DSM disorder is accompanied by a criteria set that lists in fairly precise terms which symptoms define it, how many must be present, and their required duration. For example, a major depressive episode is defined as five or more of the following symptoms, presenting together for more than two weeks and causing clinically significant distress or impairment: depressed mood; loss of interest; reduced appetite; changed sleep; fatigue; agitation; guilt; trouble thinking; and suicidal feelings. Clinicians everywhere have been using this as a consensus definition for more than thirty years. Clinical depression is not diagnosed if there are only four instead of five of these very same symptoms, or if they are present for only one week, not two, or if the impairment they cause is not all that big a deal. There are about two hundred criteria sets in the DSM—one for each disorder. These establish the boundaries that separate the mental disorders from one another and from normality. Each criteria set has the symptoms that define that particular disorder (panic, generalized anxiety, obsessive-compulsive, attention deficit, autism, etc.) and the required threshold. When clinicians follow the criteria, they achieve reasonable agreement. Without them, there is poor agreement. Each clinician becomes a law unto himself, and the result is a confusing Babel of clashing, idiosyncratic voices.

But there is a catch. The boundaries demarcating the different disorders are ever so much fuzzier in real life than they appear to be on paper. There is really nothing magical or preordained about any of the DSM thresholds—shades of gray exist between their seemingly black and white cutoff points. Requiring five symptoms and two weeks for major depressive disorder derives from a fairly arbitrary choice, not a scientific necessity. Just as easily, the set points could have been set higher—say at six symptoms and four weeks.

With a more demanding threshold, we would lose in “sensitivity” (thereby missing some sick people who are in need of diagnosis) but would gain in “specificity” (mislabeling fewer normal people). Sensitivity and specificity are reciprocally intertwined—you can’t help one without hurting the other. There is an inevitable trade-off between them that requires a proper balancing of the risks and benefits of overdiagnosis versus underdiagnosis. The final decision where to set the bar is always a judgment call; the research never renders a clear and compelling answer forcing the choice of one particular threshold in preference to other possibilities.

Once a criteria set is established, there should be good reasons for changing it; otherwise the system will be not only arbitrary, but also inconsistent and confusing. But this leads to a problem. Many of our current categories and thresholds were created thirty-five years ago when achieving sensitivity was the more important goal—too many people who needed a diagnosis were being missed. Circumstances have now changed dramatically, and poor specificity is now the biggest issue. Before DSM-III, there were too few diagnoses—now, because of diagnosis inflation, there are far too many. Raising severity and duration thresholds would help “save normal” and cure excessive diagnosis—but would create instability and reduce sensitivity. You can’t have it both ways.

The method of defining disorders by criteria sets has another inherent set of difficult-to-balance trade-offs—between “reliability” and “validity.” Reliability means agreement and consistency—will different clinicians seeing the same patient arrive at the same diagnosis. Validity means truth—will the diagnosis tell you what you want to know.

Ideally, of course, the definition of a disorder would do both—be both reliable and valid. But to meet the goal of reliability, the defining symptoms must be extremely simple, obvious, and generalize easily across all the people with that particular disorder. If the criteria set includes items that are inferential or complicated, different clinicians will disagree on whether or not they are present.

Worshiping at the temple of reliability, the DSM criteria sets are as simple as they can be—a catalog only of what is most surface and common in mental disorders. This was a necessary choice, but it necessarily compromises validity—constraining ourselves to the simple blinds us to subtlety, nuance, and individual variability. A great deal is lost in the translation between the rich diversity of different individual experiences of depression and the bland five-of-nine criteria set chosen to define it. In describing the characteristics shared by those who meet the criteria for a given mental disorder, the DSM definitions must obscure the ways they are individual and different. DSM definitions do not include personal and contextual factors, such as whether the depressive symptoms are an understandable response to a loss, a terrible life situation, psychological conflict, or personality factors.

DSM has to stay simple, but psychiatry doesn’t. DSM diagnosis should be seen as just one small part of an overall evaluation that would also comprehensively account for the more complicated and individual aspects of each patient. Unfortunately, the DSM approach has been far too influential—dominating the field in a way we never intended. Nuanced psychiatry has become checklist psychiatry, homogenizing individual differences and custom-tailored treatments. Psychiatry, once too idiosyncratic and chaotic, has become too standardized and simpleminded. Training programs focus excessive attention on teaching diagnosis and not enough on understanding everything else about the patient.37 People forget the wisdom of Hippocrates: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Of course, best practice is to pay close attention to both. DSM diagnosis has a necessary place in every evaluation, but it never tells the whole story.

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Paul R. McHugh, MD, and Phillip R. Slavney, MD, “Comprehensive Evaluation or Checklist?” New England J Med 366, no. 20 (2012): 1853–55.

Then there is the problem of knowing which criteria to choose and pretesting for their safety. Before we go prime time with a criteria set, the safe play is to audition it in a field trial. A test drive reduces uncertainty about how it will eventually perform, reducing the risk of unpleasant surprises and the dangers of unwanted fads. The idea is to have clinicians try out the new definition under conditions that approximate real-life circumstances. If the proposal performs well, it becomes official; if poorly, it is revised or scrapped. But again there is a catch. Really several different catches.

First, even the best field trial is performed in the present and can’t fully anticipate the future. The carefully done DSM-IV attention deficit predicted that our proposed changes would cause only a 15 percent increase in rates. This was probably a fairly accurate estimate given the reality when the data were gathered in the early 1990s. We couldn’t foresee the abrupt switch in this reality that occurred in 1997, when drug companies brought new and expensive medicine for ADD to market and were simultaneously set free to advertise them directly to parents and teachers. Soon the selling of ADHD as a diagnosis was ubiquitous in magazines, on your TV screen, and in pediatricians’ offices—an unexpected epidemic was born, and the rates of ADHD tripled.

Next, there is the problem of generalizability. The best setting for doing field trials would be the offices of the clinical psychiatrists and of the primary care physicians who actually write most of the prescriptions for psychiatric drugs. But because it is easier, field-testing is instead done in samples of convenience drawn from university research clinics that are very unlike the sites of eventual greatest misuse. The results generated in these cloistered settings will always be much better than what will be obtained in the hustle and bustle of the real world.

Then there is the distorting effect of observing the thing observed. It is inherently impossible to learn everything about an electron because the act of observing an electron changes its momentum. Similarly, the act of observing everyday diagnostic practice distorts it so that it is no longer everyday. The selection and training of the clinicians, and their focused attention, make them better diagnosticians within a study than they will be outside of one.

Patient selection in a field trial also artificially raises reliability. In real life, making a diagnosis is like finding a needle in a haystack containing hundreds of possible choices. The field test presents a much easier challenge to the clinician. He knows he is selecting from among only a handful of different choices. Bottom line: Field trials are absolutely necessary but extremely fallible. New suggestions will perform much better in the trial than in real life. Possible future misuses may be entirely undetectable and unpredictable. At their best, field trials will help you avoid some, but certainly not all, the possible future trouble spots.

One final interesting question: Should we use names or numbers in defining mental disorders? The DSM system uses only names. Psychologists have developed thousands of rating scales that instead use numbers. Which is better? Like most things, there is no one right answer—it depends on your purpose. Numbers are much more accurate than names—that’s why we use them to measure height, weight, IQ, or wavelength in physics. When describing someone’s place on a graded continuum, it is ever so much more precise to give a number than a name. “He is six feet tall” saves information lost if the description is reduced simply to “He is tall.” Computers love numbers. And so do the researchers who use them.

But most people think names, not numbers. Evolutionary pressures shaped our minds to give simple names, not to make fine-grained mathematical distinctions. We are adapted to a world that required quickly choosing between a yes or no—trying to quantify predators too closely might get you eaten. It’s no surprise that statistics as a branch of mathematics arose so late in the game—just a few hundred years ago.

In everyday life, we still usually prefer names to numbers—even though names are admittedly inexact and we do have eager computers ready to crunch whatever numbers we throw at them. We label a color “red” (rather than calling out its exact wavelength) because this is quicker, easier, clearer, and usually serves the purpose. A vivid name, not a confusing bunch of numbers, remains much more convenient for most tasks and provides a clearer and more readily understood image. Clinicians are busy people who have thought in names every step of their natural lives and in all their training. They will not switch to numbers easily, and patients wouldn’t understand them if they did. Computer-assisted dimensional diagnosis is certainly the wave of the future, but it is premature and impossible to implement in the present. For now, we will stick to naming the mental disorders, not numbering them.

At the extremes, the distinction between the completely well and the clearly sick is perfectly plain and not the least bit amenable to fudging. In contrast, the much fuzzier distinction between the mildly ill and the probably well is easily and frequently manipulated. Most normal people have at least occasional mild and transitory symptoms (e.g., sadness, anxiety, sleeplessness, sexual dysfunction, substance use) that can easily be misconstrued as mental disorder. The business model of the pharmaceutical industry depends on extending the realm of illness—using creative marketing to expand the pool of customers by convincing the probably well that they are at least mildly sick. Disease mongering is the fine art of selling psychiatric ills as the most efficient way of peddling very profitable psychiatric pills. Manipulating the market is particularly easy in the United States because we are the only country in the entire world that allows drug companies the freedom to advertise directly to consumers.

Disease mongering cannot occur in a vacuum—it requires that the drug companies engage the active collaboration of the doctors who write the prescriptions, the patients who ask for them, the researchers who invent the new mental disorders, the consumer groups that advocate for more treatment, and the media and Internet that spread the word. A persistent, pervasive, and well-financed “disease awareness” campaign can create disease where none existed before. And psychiatry is especially vulnerable to manipulation of the normal/disease boundary because it lacks biological tests and relies heavily on subjective judgments that can be easily influenced by clever marketing.

The primary loyalty of any corporation is to its shareholders and to its own-survival, not to the public weal. General Motors sells cars, Anheuser-Busch sells beer, Apple sells computers, the drug cartels sell cocaine, and drug companies sell pills all for the same reason—to generate as big a profit as possible. The profitability of any corporation depends on increasing the size of its market and its margins on each sale. Drug companies are exemplary profit-making machines because of their highly developed skill in pushing product and their ability to maintain monopoly pricing. Pumping up diagnostic inflation is absolutely key to drug company success. Full saturation requires having the widest demographic reach, from the youngest child to the oldest adult. Casting the broadest net is always great for shareholders, but is very often bad news for the mislabeled normals who are subjected to the unnecessary medication and stigma that comes with fake diagnosis.

Is Normality Resilient or Fragile?

The paradoxical answer is both. Resiliency is built into every aspect of our biological, psychological, and social being. We are hardwired to work remarkably well, but are far too complicated always to work perfectly and we can lose purchase on normality by mislabeling as mental disorder each and every one of our glitches.

The governing principle of all of life is “homeostasis”—a portmanteau word that combines the Greek terms “homeo” (same) with “stasis” (stable) to doubly emphasize the pursuit of equilibrium. At every level from the single cell to the entire society, nature constantly seeks to compensate for all perturbations and to reestablish stable balance to return to whatever is the normal or expectable range of function. Systems don’t survive very long unless they can achieve homeostasis in the face of both external and internal challenges and disruptions. Each of our cells is a complex and hardworking factory whose survival depends on maintaining the proper metabolic balance of millions of chemical interactions. Each organ is a collaboration of cells and our body is a collaboration of organs, each dependent for its survival on the balanced functioning of all the others. Homeostasis is what keeps our body temperature, blood pressure, and pulse rate stable. Our body is a constant wonder of billions of trade-offs.

In the interpersonal realm, marriages end in divorce if they lack the homeostatic gift of smoothing the rough edges of inevitable conflict. In the political realm, states that can’t find homeostatic balance among competing forces suffer civil war or collapse. Homeostasis also governs any inanimate physical or chemical processes that are in a prolonged steady state. We would not have our comfortable home in this solar system were it not in a state of gentle homeostatic equilibrium—a delicate balance that we are now threatening by pollution and overpopulation.

Any failure of homeostasis in an animate system leads to malfunction, disease, and eventually (if severe and prolonged enough) death. Cancer, diabetes, hypertension, heart failure, obesity, and most other illnesses all represent the breakdown of homeostatic feedback mechanisms that normally keep our bodies in balance. And medical treatments for illness all have in common the aim of restoring an internal balance that has been lost in the face of disease.

The human brain is our world’s grandest expression of homeostasis. It is the master regulator of most of our bodily functions and also a master at regulating that most complex of all machines—itself. Our thoughts, emotions, and behaviors are the final result of an indescribably complex coordination of billions of cells firing off in a carefully tuned, exquisite equilibrium. No computer engineer would have the audacity (much less the ability) to create something so complex—too many things could go wrong along the way. And doubtless they do. But nature has found the means to provide good enough wiring and compensatory balance most of the time. Brain homeostasis has sufficient resources and redundancies to react to internal and external challenges, bringing things back to normal and keeping us functioning pretty much within the straight and narrow.

We are hardy survivors—men and women for all seasons, built to work in all climates, to eat every conceivable food and to survive long periods without food, to fight battles and to run away, to love and to hate, to feel a wide gamut of emotions, and to evince a startling array of different behaviors. We are not only much alike but also preserve specialized individual differences essential for the survival of the small groups that endured the rigors of the past hundreds of thousands of years. The tribe needed the proper balance of many individual capacities—it would not do well with all leaders or all followers, with all warriors or all pacifists, if everyone was paranoid or gullible.

We can feel sadness, grief, worry, anger, disgust, and terror because these are all adaptive. At times (especially in response to interpersonal, psychological, and practical stresses), our emotions may temporarily get out of hand and cause considerable distress or impairment. But homeostasis and time are great natural healers, and most people resiliently right themselves and regain their normal balance. Psychiatric disorder consists of symptoms and behaviors that are not self-correcting—a breakdown in the normal homeostatic healing process. Diagnostic inflation occurs when we confuse the typical perturbations that are part of everyone’s life with true psychiatric disorder (which is relatively uncommon, perhaps affecting 5 to 10 percent of the population at any given time).

Mental disorders should be diagnosed only when the presentation is clear-cut, severe, and clearly not going away on its own. The best way to deal with the everyday problems of living is to solve them directly or to wait them out, not to medicalize them with a psychiatric diagnosis or treat them with a pill. Prematurely resorting to medication short-circuits the traditional pathways of restorative natural healing—seeking support from family, friends, and the community; making needed life changes, off-loading excessive stress; pursuing hobbies and interests, exercise, rest, distraction, a change of pace. Overcoming problems on your own normalizes the situation, teaches new skills, and brings you closer to the people who were helpful. Taking a pill labels you as different and sick, even if you really aren’t. Medication is essential when needed to reestablish homeostasis for those who are suffering from real psychiatric disorder. Medication interferes with homeostasis for those who are suffering from the problems of everyday life.

A study we did twenty-five years ago taught me an unforgettable lesson about human resilience. It was at the height of the AIDS epidemic and before there were any effective treatments. Getting a positive test result was then the equivalent of a death sentence—and a very unpleasant death at that. We found that men who tested positive had an immediate large jump in measures of sadness and anxiety—no surprise, given the fatal implications of the test. Men who tested negative had a smaller, but still large, reduction in these same measures—again no surprise that they would be greatly relieved. Really amazing were the scores six weeks later. Both groups had returned pretty much to their baselines—the HIV positives were resiliently dealing with their really terrible news; the HIV negatives did not get a permanent mood lift from their really wonderful news. Homeostasis had brought both groups back to where they started. Had we immediately jumped in with medication to treat the painful symptoms in the positives, we would have interfered with their natural healing and given them another burden to add to the ones they already had. The lesson is clear—we have far too much faith in pills, far too little trust in resilience, time, and homeostasis.

Normal Is Fuzzy and Therefore Fragile

“Normal” and mental disorder turn out to be a frustratingly elusive—inherently incapable of anything resembling clear, bright-line definition. The realm of the “normal” has been rapidly shrinking as an expanding psychiatry stretches easily across its elastic boundary. Are my son’s temper tantrums part of growing up or an early sign of bipolar disorder? Does my daughter’s inattentiveness at school mean she has attention deficit disorder or is she just extra smart and bored with the dull stuff being covered there? Should I be pleased by my son’s precocious interest in rockets and science fiction or worried that he is autistic? Am I experiencing expectable worries and sadness or is this generalized anxiety disorder? If I don’t remember a face or a fact, is Alzheimer’s just around the corner? Is grief a useful, inevitable, and poignant sign of my broken heart, or is it a major depressive disorder? Is my teenage daughter a creative eccentric, or a psychotic-to-be who needs a dangerous drug? Is Tiger Woods a mental patient or a philanderer? Is a brutal rapist simply bad or possibly mad? All of us have mild and transient psychiatric symptoms from time to time—does this mean we are all flirting with mental illness?

Questions about what’s normal and what causes abnormal have been with us since the dawn of man. Our ancestors found creative answers that always made good sense to them at the time. Some now seem brilliantly intuitive, others daffy, and a few were positively diabolical. A quick detour through this past will help us understand the present and avoid mistakes in the future.

Notes

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🔮 The Cosmos