It is inevitable that we, as humans, experience some sort of distress or suffering at some stage of our lives. This pure nature of the human life makes it something so complex and even interesting. So, what is the real boundary between normal distress and a mental disorder? And are the diagnostic systems that clinicians use still practical and feasible to set this boundary of what is normal and what is not?
To my surprise, according to the DSM 5 – the newest edition of the Diagnostic and Statistical Manual of Mental Disorders - I actually qualify to have a mental disorder. Yeah, it falls under the DSM-5 Caffeine-Related Disorders and goes by the name of Caffeine Withdrawal Syndrome. Sincerely, I am a little offended. Just because I did not get that normal dose of warm little cups of caffeine goodness and am therefore experiencing headaches, with the sense of nausea and low energy levels, my psychologist can actually diagnose me with a mental disorder, while additionally prescribing me to a treatment after assessing my symptoms that have been present for a mere few days?! Isn’t it quite normal to have withdrawals when we do something every day and it’s suddenly taken away? When something we love is removed from us, it hurts because we are human. This is our most natural and pure reaction. So why classify me as abnormal when I want what I love back in my life? And why should I be over my love of coffee in simply A FEW DAYS? This wasn’t just a weekend fling!
The reason I think it is a controversial addition to the DSM, is not because I am in denial of my slight obsession for coffee. I will admit that I am quite adamant on getting coffee in bed and do get tired and even light-headed when I don’t get coffee within the first few hours of waking up. However, the real reason why I see it as controversial is because the symptoms are being classified as a whole mental disorder!
Now, according to the DSM 5, a mental disorder is - for example - a syndrome that is characterized by a clinically significant disturbance in an individual’s cognition, emotion or behavior. Yet, the DSM fails to define and have guidelines for what the term "clinically significant" means or what level of disturbance is considered clinically significant. Thus, it seems to be purely based on the clinician’s observation. Where and how is the true difference set between, “I am acting normal because I have had my ritual cup of coffee” and “I am not acting normal because I did not have my ritual cup of coffee”?
Furthermore, the DSM also states that for a syndrome to be a mental disorder, it “usually has to be associated with significant distress in social, occupational roles and an impairment in functioning." The word ‘usually’ in the description suggests it can, most of the time, but it also cannot, at times. Again, the wording is too ambiguous. It does not set a clear outline for what a mental disorder is and what it is not. Why are we categorizing a list of physical symptoms to a psychological term that has such a vague definition? In a nutshell, the DSM 5 lacks to operationalize what a mental disorder is, which makes it incredibly easier to pathologize normal symptoms that are part of our human experience, especially if we do not take a client’s social and cultural context into mind.
Another quite disputable condition that has been listed for future diagnostic inclusion in the upcoming edition of the DSM, is known as Persistent Complex Bereavement Disorder. For me to be diagnosed with this mental disorder, such as if I were to lose a loved one, I must meet five criteria:
- Criterion A, I must experience the death of someone with whom I had a close relationship with. Okay, duh?
- Criterion B, I must often experience either intense pain and sorrow in response, be preoccupied with the death, have preoccupation with the circumstance thereof or longing for the deceased to a clinically significant degree for 12 months. Am I supposed to feel no sorrow and pain if the one year has passed? At all?
- Criterion C, since the death I would have to experience some sort of reactive stress for 12 months, such as having difficulty accepting the death, self-blame, or anger. I would also have to experience some disruption in terms of my social life and identity for 12 months. For example, feeling detached from people, having trust issues, feeling empty or struggling to plan my future without the deceased. Waaaaiit. Doesn’t this all just seem like a natural bereavement process and not as a disordered grief? In fact, I would say the person not experiencing these symptoms after they had lost someone close, does NOT seem normal.
- Criterion D states that the above symptoms of criteria B and C should cause me clinically significant distress or impairment in functioning. This could, for instance, be measured in terms of how much it impairs my ability to go on with my life a year after the death. Criteria D does seem relatively helpful to determine whether my grief response is inappropriate and excessive, but yet again, the time frame of 12 months being the cut-off limit for the symptoms to be comprehended as normal, is not enough evidence to make a decision about what is the expected time length one can engage in a grieving process. What about the contextual and personal factors? Wouldn’t it take much more time to grieve if my loved one died unexpectedly and not of a natural cause?
- The last criterion includes that the reaction must be out of proportion with my cultural, religious, or age-appropriate norms. In this case, is the clinician prescribed to do a mandatory assessment to make a sound estimation in terms of MY culture, MY religion, or MY development to know which reaction to the loss is proportional to my norm?
It has been an increasing problem for the past 20-30 years, that we are adding new mental disorders to the list that should be classified as normal human behaviour. Nonetheless, pathologizing normal human experiences is not the only contribution to the diagnostic inflation. We also see a rise in the number of people being diagnosed, because of the lowering of the diagnostic threshold that makes it so much easier to meet a diagnostic criterion. For example, the previous edition of the DSM included a bereavement exclusion for major depressive disorder. So, in the past, a person that is experiencing symptoms of depression for less than 2 months and who had recently lost someone close to them, would not be eligible to meet the diagnostic criteria for depression. The new edition of the DSM 5, however, included a checklist for symptoms of depression you have to meet with no reference to context or aetiology, completely eliminating the bereavement exclusion. In other words, if you lose a loved one and have symptoms of depression, you are eligible to be diagnosed with depression. Again, we are categorizing an appropriate response over a lost loved one as a mental illness. Thus, the DSM is making a comorbidity out of an actual disorder, a sensical grieving process and major depressive disorder. Of course, you can expect the number of people being diagnosed with major depressive disorder to double now!
I think it is of great importance for us, as a society, to save some normality of the human mind and life - not everything should be seen outside of the norm of living life. Thus, the clinician needs to really get to know their client, use critical reflexivity and take in a much broader perspective of the client’s social context and individualistic symptoms. If clinicians do consider this manual as the universal truth of mental disorders, soon the whole world will be qualified to be mentally ill.