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Does Psychiatry Medicalize Normality?
Ronald Pies MD argues that it doesn’t.
“If sick men fared just as well eating and drinking and living exactly as healthy men do… there would be little need for the science [of medicine].”
There has been a great deal of controversy surrounding the recent release of the DSM-5: the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the orthodox reference work for psychiatric diagnosis. Critics claim that it ‘medicalizes’ normal human emotions and reactions. Yet this claim has been subject to very little logical analysis. For the proposition ‘psychiatry is medicalizing normality’ to be true, we would need, first, adequate definitions of the terms ‘medicalizing’ and ‘normality’; and second, convincing evidence that psychiatry is actually doing what the proposition asserts. Yet both elements turn out to be problematic. In this article, I argue that the claim that ‘psychiatry medicalizes normality’ is based on certain questionable assumptions and confusions, and that DSM-5 is also a relatively conservative document with respect to the creation of new categories of disorder.
What Does ‘Medicalize’ Mean?
To start with, based on my reading of many posts and articles critical of psychiatry, the term ‘medicalize’ seems to be used in at least four ways, to denote:
1.) The inappropriate labeling of a normal condition or normal ‘problem of living’ as a disease, disorder, or illness;
2.) The assertion that a condition or state of affairs requires the services of a nurse or physician;
3.) The assertion that a condition is due to disturbed physiology, a chemical imbalance, or some other bodily defect; or
4.) The assertion that a condition requires treatment, such as medication, Electro-Convulsive Therapy, etc.
We are not helped very much here by scholars who have attempted a definition of ‘medicalization’. For example, the medical sociologist Peter Conrad writes in his book The Medicalization of Society (2007), “‘Medicalization’ describes a process by which non-medical problems become defined and treated as medical problems, usually in terms of illness and disorders.” (p.4.) But this definition is transparently circular; that is, it assumes that a certain class of conditions are ‘non-medical’, but then, for whatever reason, come to be viewed as ‘medical’, yet it provides no necessary and sufficient criteria by which these two classes ‘non-medical’ and ‘medical’ are to be defined. Moreover, the author states, “I am not interested in adjudicating whether any particular problem is really a medical problem. This is far beyond the scope of my expertise…” Thus, he acknowledges his inability to adjudicate the validity of the claim ‘X is really a medical problem’, while simultaneously defining ‘medicalization’ in terms of conditions that are ‘medical’ or ‘non-medical’!
That famous critic of psychiatry, the late Dr Thomas Szasz, highlighted the fundamental philosophical problem Conrad’s formulation raises. Szasz wrote, “The concept of medicalization rests on the assumption that some phenomena belong in the domain of medicine and some do not. Accordingly, unless we agree on clearly defined criteria that define membership in the class called ‘disease’ or ‘medical problem’ it is fruitless to debate whether any particular act of medicalization is ‘valid’ or not.” (The Medicalization of Everyday Life: Selected Essays, p.xiii, 2007.)
While I have radically different views from Szasz on mental illness, I believe he was entirely correct in this particular claim. Indeed, the problem for those who argue that psychiatry is medicalizing normal human conditions is precisely what Szasz anticipates: there has never been, nor is there now, any universal agreement on membership of the class called ‘disease’. The denotation of the term ‘disease’ has always been in flux, if not in overt dispute, even during the time of Hippocrates. Consider for example this rather breathtakingly broad definition of ‘disease’ from the 8th edition of Harrison’s Principles of Internal Medicine (1977): “The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, all conditions that limit life in its powers, enjoyment, and duration.” (p.1, italics mine.) The editors go on to say that the physician’s “primary and traditional objectives are utilitarian – the prevention and cure of disease and the relief of suffering, whether of body or of mind…” (ibid.)
Note that in this description of disease, there is no implication that disease refers to bodily pathology alone. The emphasis, rather, is on the presence of suffering and incapacity (“conditions that limit life in its powers”). It is fascinating to note that in the 14th edition of Harrison’s Principles (1997), the unmodified term ‘disease’ does not even appear in the index, nor – so far as I can tell – is the term actually defined in the entire text.
All this leads us to an inescapable conclusion: that unless we have a universally recognized ‘taxon’ – a set whose membership is defined by necessary and sufficient criteria – there is no test to determine what does or does not lie within the bounds of the category ‘disease’ (i.e., as a medical problem). Therefore, arguments about psychiatry’s medicalizing normality cannot be settled through scientific methods. Rather, such debates are essentially political-rhetorical exercises, not arguments about empirically verifiable claims. Of course, this doesn’t mean that the debate is unimportant, or without practical implications for our classification of psychiatric diseases.
Paradoxically, those who argue that psychiatry medicalizes normality but who simultaneously assert that there is no clear demarcation between normality and abnormality effectively refute their own argument. For if there are no absolute, categorical boundaries separating ‘normal’ from ‘abnormal’, then the claim ‘psychiatry is medicalizing normality’ cannot logically be sustained. That is to say, if ‘normality’ has no precise boundary in the medical realm – including psychiatric medicine – then there can be no verifiable medicalization of normality. Neither can there be a fact-based demonstration of psychiatry’s alleged ‘diagnostic imperialism’, nor its supposed creation of diagnostic ‘false positives’. Such claims are no more verifiable than a landowner’s complaint that someone has impermissibly planted a tree on his property when there are no clearly established property lines. (However, this doesn’t mean that we can’t make reasoned, empirically-grounded judgments as to what conditions merit medical evaluation or treatment.)
There is also a problem with the claim that psychiatry imposes ‘the medical model’ on ‘perfectly normal problems of living’. When critics of psychiatry use the term ‘medical model’ in a derisive way, they seem to have in mind what Shah and Mountain describe as a “paternalistic, inhumane and reductionist” model of understanding illness (‘The Medical Model Is Dead – Long Live The Medical Model’, The British Journal of Psychiatry, #191, 2007). Yet as they point out, the medical model needn’t have these characteristics. Understood more broadly, it might simply denote “a process whereby, informed by the best available evidence, doctors advise on, coordinate or deliver interventions for health improvement” (ibid).
In any case, it seems clear that the term ‘medicalization’ has many possible meanings, so when critics accuse psychiatry of ‘medicalizing’ normality, it is far from clear what they mean.
Problems With ‘Normality’
If ‘medicalization’ is difficult to define, the term ‘normality’ is even more problematic and elusive, if not hopelessly vague. It seems to have an almost limitless range of meanings; for example:
1.) The usual state of affairs in ‘healthy’ or ‘normal’ persons (whatever ‘healthy’ and ‘normal’ mean);
2.) Any condition or set of conditions that occur with high frequency, or more often than not, in most populations;
3.) The inherent qualities and characteristics of most human beings.
The philosopher Roger Aboud has highlighted the difficulties in defining ‘normality’, noting that it may be a mathematical, evaluative, or biological term. Specifically, he writes, “The biological concept of normality is problematic because it refers to the subjective meaning of ‘healthy’ and may not point to the average, majority, or ideal… Behavioral concepts of normality also suffer from subjective meaning and are contextually problematic, related to definitions of average, majority, or ideal.” (‘Wachbroit’s “Normality and the Significance of Difference”’ 2008, accessible at driftingconsciousness.blogspot.com.)
In sum, the two elements in the claim that ‘psychiatry is medicalizing normality’ are so semantically diverse as to be nearly indecipherable. It is therefore nearly impossible to determine whether psychiatry is actually doing what the proposition asserts.
No Extra Pathologies
It is also noteworthy that DSM-5 does not appreciably increase the number of diagnoses contained in DSM-4, according to an official release by the American Psychiatric Association (Dec. 1, 2012). Indeed, a well-informed official connected with DSM-5 informed me that it contains fewer disorders in total than DSM-4. Based on this fact alone, it is hard to make the charge that psychiatry medicalizes normality stick. Moreover, while DSM-5 does create some new and controversial categories, such as ‘Disruptive Mood Dysregulation Disorder’, it also turned down several proposed illnesses, such as ‘Anxious Depression’, ‘Hypersexual Disorder’, and ‘Parental Alienation Syndrome’ – diagnoses which might be interpreted as extending the reach of psychopathology into the realm of normality. Similarly, several other conditions that had been proposed for inclusion, such as ‘Attenuated Psychosis Syndrome’ and ‘Internet Use Gaming Disorder’, were relegated to Section 3 of DSM-5; i.e., conditions that “require further research before their consideration as formal disorders.” Finally, the historical subtypes of schizophrenia – paranoid, catatonic, disorganized, etc. – have been eliminated. Overall, these trends do not point to increasing medicalization of normality.
That said, I believe that the diagnostic threshold for some DSM disorders continues to be set too low. For example, my colleagues and I believe that the two week minimum duration criterion for diagnosing Major Depressive Disorder (MDD) is often too brief, giving clinicians too little time to judge the patient’s response to a major loss – whether in the context of recent bereavement, job loss, divorce, or any other major life stressor (see Lamb K., Pies R., Zisook S., ‘The Bereavement Exclusion for the Diagnosis of Major Depression: To be, or not to be’, Psychiatry, 7(7), 2010). Furthermore, the diagnostic criteria for MDD are so broad as to create an overly-heterogeneous population identified with the illness. How useful is it to bracket somebody who has been depressed for two weeks following a bereavement with patients who have had symptoms of depression for over a year?
In my view, the term ‘medicalization’ has become a kind of rhetorical Rorschach test: it evokes whatever political, social, or philosophical position the reader happens to hold or wants to advocate. It is not a scientific term, nor one that can be otherwise defined according to widely accepted empirically-derived principles. Furthermore, to the extent that the term ‘medicalization’ can be meaningfully defined, it is by no means clear that physicians alone bear responsibility for the phenomenon. In this respect, I’m in agreement with Peter Conrad, who writes, “Many of the earliest studies assumed that physicians were the key to understanding medicalization. Illich… used the catchy but misleading phrase ‘medical imperialism’. It soon became clear, however, that medicalization was more complicated than the annexation of new problems by doctors and the medical profession. In cases like alcoholism, medicalization was primarily accomplished by a social movement [Alcoholics Anonymous]…” (The Medicalization of Society, p.6.)
Furthermore, while it is arguably the case that many challenging aspects of the human condition lie outside the purview of medical diagnosis and treatment – everyday sadness or fleeting anxiety, for example – there is also a flip-side to the claim that too many conditions are being medicalized. This is nicely expressed by Vikki Stefans, MD, Associate Professor of Pediatrics and Associate Professor of Physical Medicine and Rehabilitation at the University of Arkansas for Medical Sciences:
“a person is labeled mean and hateful when they are really terribly depressed and irritable… or… a child is labeled lazy, considered the class clown, or seen as an academic problem – maybe even suspended or put in special education – when they have an undiagnosed specific learning disability or [ADHD]… A child returning to school after a concussion or brain injury still has a good chance of being labeled lazy or uncooperative when they can’t perform at their previous level. Kids with spina bifida or [cerebral palsy] even have parents who think they are lazy for not maintaining their posture or turning a foot in or out because ‘they can do it when they want to’. And how about ‘she’s just a little shy’ being applied to a case of elective mutism that is totally limiting and impairing a person’s life? Sometimes, people want to normalize pathology, too!”
(Personal communication, 4/29/13.)
There may, indeed, be good and bad forms of medicalizing, as Erik Parens, a senior research scholar at The Hastings Center, has argued. For example, applying the medical model to alcohol addiction might be an example of good medicalizing; whereas applying it, say, to the feelings of sadness one experiences upon the break-up of an intimate relationship, might be considered a bad form of medicalizing. In any case, as Parens rightly observes, “the idea of medicalization depends upon the notion that medicine has ‘proper’ goals, which are visible to those with knowledge of the essence of medicine… [but] one needs a narrow conception of those goals to get traction for the medicalization critique. Without a narrow conception, one can’t restrict the range of the targets that medicine ‘properly’ aims at.” (‘On Good and Bad Forms of Medicalization’, Bioethics, 27(1), 2013.) Yet if, as I believe, the broad and overarching goal of medicine as a whole and psychiatry in particular is the relief of suffering and incapacity, it would seem that the range of targets for medical intervention is wide indeed. So, while the term ‘medicalizing’ may be useful in calling our attention to trends in medical diagnosis, it greatly oversimplifies the realities of medical care and human suffering.
© Dr Ronald Pies 2013
Ronald Pies, Professor of Psychiatry at SUNY Upstate Medical University and Tufts University, is the author of The Three-Petalled Rose, and other books of philosophy.
• Many thanks to Eric Parens PhD, and to Vikki Stefans MD, for their collegial assistance with aspects of this article.