At the edge of a state of mental illness, there is a boundary with normality. But where are the edges? These days we see one of the edges of mental illness becoming clearer, and another one becoming fuzzier. Strangely, the clear one is easier to lose sight of than the fuzzy one.
The relatively clear one is the definition of mental disorder in the DSM (the American Psychiatric Association’s Diagnostic and Statistical Manual), which is a classification of mental illness by groups of symptoms that are commonly associated. Some people even go so far as to think that these groups of commonly-associated symptoms are distinct disorders — that is, that the grouping matches underlying causes, though the DSM does not claim that.
When a patient is diagnosed along DSM lines it is unsettling, though, and it undermines confidence in mental health professionals, when the diagnosis changes because the condition has progressed or more is now known about it. People find it difficult to imagine that they were suffering first from one distinct disorder and then from another. They tend to assume that one or other diagnosis was wrong, or perhaps both are wrong, or the whole of psychiatry is wrong. The language of psychiatric diagnosis does not match the reality of overlapping symptom clusters.
As the American Psychiatric Association’s FAQ on DSM-5 acknowledges:
…there are real-world problems with this system of diagnosis. The categorical syndromes do not always fit with the reality of the range of symptoms that individuals’ experience.
The way drugs are marketed tends to follow the DSM classification, too, because that’s the easiest way for a pharmaceutical company to get its message across about a new product. Again, when a drug that was initially marketed to treat one diagnosis then turns out to be effective for another diagnosis, it is confusing if you make the mistake of thinking that each diagnosis is a distinct disorder.
Starting from the set of symptom clusters in DSM-IV, what could possibly be different in the forthcoming DSM-5 (in addition to the change from Roman to Arabic numeral in the title)? The only possible changes are in the symptom information being considered, and in the boundaries between clusters. Both kinds of change are proposed for DSM-5.
If those are the kinds of changes expected, what about the direction of change? Theoretically, DSM-5 could be a simplification or an expansion, but no one involved in producing DSM-5 would benefit from a simplification. So DSM-5 will expand psychiatric diagnosis by making it more complicated, by including new information about symptoms, and by tinkering with the boundaries between the symptom groups described in DSM-IV.
None of this tinkering looks likely to affect the DSM’s definition of mental disorder very much, though a few clarifications are proposed. The key feature of a mental disorder is usually this one (the third of the five main features proposed as the Definition of a Mental Disorder for DSM-5):
Must not be merely an expectable response to common stressors and losses (e.g. the loss of a loved one) or a culturally sanctioned response to a particular event (e.g. trance states in religious rituals)
Another example given in the paper What is a mental/psychiatric disorder? From DSM-IV to DSM-V (sic) by Stein, et al., referred to in the proposal, is of someone who is shy in social situations. Social situations are a common stressor and the shyness is a response that it is possible to expect, so the shyness is not a mental disorder if it only occurs in relation to those situations.
The example of trance states is a proposed clarification in DSM-5, strengthening the criterion by pointing out that even quite extreme mental states are not necessarily mental disorders.
As an aside, it is intriguing that the paper undermines its own position by suggesting that treatment might still be appropriate for people who do not have any disorder:
…people experiencing such normal responses may well present for evaluation and treatment, and they may be helped by a brief intervention such as psychotherapy and monitoring…
The boundary between normal mental states and mental disorder is a fairly clear one in practice. Anyone can go through the list of criteria in any particular case and make a judgement about it. That is not to say that everyone will always make the same judgement, but even so, the criteria work.
At another edge of mental illness there are people who, in DSM terms, are clearly very ill, but the precise classification of their symptoms is regarded as irrelevant because they cannot be treated.
The reason they cannot be treated might be because no one in the vicinity knows how to do it, or because it would be too expensive, or because it would take too long. So there is apparently nothing much that can be done for these people.
There is a growing realization, however, that absence of symptoms is not all there is to life. A new definition of ‘recovery’ denotes it (like in Orwellian newspeak) as meaning the opposite of what it used to mean. Before, recovery meant your symptoms went away. Now, recovery means you still have your symptoms but you carry on regardless.
The boundary between people who are ill but treatable (so their symptoms go away) and people who can only be expected to ‘recover’ in this newspeak sense is a fairly fuzzy boundary. Someone untreatable in one county might be treatable in another. Someone untreatable in a care home might be treatable if anyone cared. There is no set of criteria that can be applied in a consistent way to determine who is who.
A good guide to the recovery idea is the Mental Health Recovery Star. The star itself is a ten-pointed star in which each point represents an area of life. Only one of the points is “Managing mental health” and this emphasizes how mental health issues, as such, play a relatively minor role in recovery.
Indeed, managing mental health does not necessarily involve overcoming symptoms (p. 8):
This is not necessarily about not having any more symptoms or medication, though this may happen. It is about learning how to manage yourself and your symptoms and building a satisfying and meaningful life which is not defined or limited by them.
Within each of the ten points of the star, there is a ten-step ‘ladder’ to track your progress (shown as numbered circles in this version). The lowest rung on each ladder is being stuck but not even considering doing something about your problems, while the highest is being self-reliant. Engaging with treatment gets a mention, but only as one part of one rung of the managing mental health ladder.
What these two approaches to mental disorders have in common is that they both identify who is not ill. They are a kind of undiagnosis. They take people out of the mental health system. They say, “These kinds of people do not need treatment.” Unfortunately both approaches have their own problems in practice.
The DSM definition suffers from the problem that many professionals (and Internet self-diagnosers) completely ignore it. The great temptation is to turn first to the lists of symptoms and look for any that seem to fit. The DSM approach means that too many normal people fall over the edge into psychiatric diagnosis and treatment. It would be helpful if the DSM could make the edge of diagnosis more visible.
The ‘recovery’ approach suffers from the opposite problem. The great temptation is to ignore diagnosis altogether. Thus, too many people who could be treated fall out of diagnosis and continue to live with their disabling symptoms. It would be helpful if part of promoting recovery could be to make the edge of diagnosis more clear.