Diagnostic labels are proliferating, and mental disorders seem to be annexing ever more territory. At the same time, many people with diagnosable conditions are forging their own original takes on what's normal.
Toward the end of my psychiatric residency, a friend pulled me aside to ask a question: Was he normal?
Peter D. Kramer, is an American psychiatrist and faculty member of Brown Medical School specializing in the area of clinical depression.
Editor: Nadeem Noor
During sex, Jack's girlfriend, Ann, let her Irish setter share the bed. Since the dog took an interest in the proceedings, the arrangement made Jack uncomfortable. When Jack expressed misgivings, Ann attacked him as obsessive. Jack told Ann that he would be seeking my opinion. Good, she said. I was just the guy.
Was Jack neurotic? Was Ann perverse? I chose not to answer; with or without diagnoses, the two would break up (presently, they did) or enter the sort of stable relationship where the woman calls the man fussy and the man considers the woman irrational. But I did note that my role—fledgling psychiatrist—now qualified me to adjudicate: Who is normal?
I have been thinking a good deal about normality lately. It's a concern in the medical world. The complaint is that doctors are abusing the privilege implied in Jack's query, to define the normal. Ordinary sadness, critics say, has been engulfed by depression. Boyishness stands in the shadow of attention deficits. Social phobia has engineered a hostile takeover of shyness.
A spate of popular books—The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder by Allan V. Horwitz and Jerome C. Wakefield, The Last Normal Child by Lawrence H. Diller, and Shyness: How Normal Behavior Became a Sickness by Christopher Lane—challenge what they believe is psychiatry's narrowing of the normal. The National Institute of Mental Health reports that in any given year, over a quarter of Americans—and over a lifetime, half of us—suffer a mental disorder.
The fate of normality is very much in the balance. The American Psychiatric Association is now revising its diagnostic and statistical manual—the next version, DSM-V, should preview in 2011 and become official the following year. It may, indeed, be that as labels proliferate, mental disorders will annex ever more territory. But claims of a psychiatric power grab are overstated. The real force behind a proliferation of labels is the increasing ability of technology to see us as we've never been seen before. Still, the notion of a shift in the normal invites unease: To constrain normality is to induce conformity. To expand diagnosis is to induce anxiety. Is anyone really well?
It's a short hop from critiquing narrowed normalcy to claiming that we are an overmedicated nation. As Lane writes, "We've narrowed healthy behavior so dramatically that our quirks and eccentricities—the normal emotional range of adolescence and adulthood—have become problems we fear and expect drugs to fix." Psychiatry's critics also complain that doctors medicate patients who meet no diagnosis, who practice what I have dubbed "cosmetic psychopharmacology," to move a person from one normal, but disfavored personality state, like humility and diffidence, to another normal, but rewarded state, like self-assertion.
Labels matter even when medication has no role in treatment. A wife complains that her husband lacks empathy. Does he have Asperger's syndrome, a lesser variant of autism, or is he simply one of those guys who "don't get it," who simply don't see social interactions as ordinarily perceptive women do?
Diagnosis, however loose, can bring relief, along with a plan for addressing the problem at hand. Parents who might have once thought of a child as slow or eccentric now see him as having dyslexia or Asperger's syndrome—and then notice similar tendencies in themselves. But there's no evidence that the proliferation of diagnoses has done harm to our identity. Is dyslexia worse than what it replaced: the accusation, say, that a child is stupid and lazy?
The question of normality creates strange paradoxes in the consulting room. Often it is relatively healthy people who feel defective. In psychotherapy, patients may perseverate over vague complaints, feeling off-balance and out of sync. The worriers may believe that they have too much or, more often, too little ambition, desire, confidence, spontaneity, or sociability. Their keen social awareness (a strength), when tinctured with obsessionality, causes them to fuss over glitches in the self. For them, a sense of abnormality precedes any diagnosis and may persist even when none is proffered.
In contrast, seriously ill patients may have no such concern. Those who manifest frank paranoia will insist on their normality; anyone would be vigilant in the face of plots directed at them. Anorexics and alcoholics may profess certainty that they're fine; the degree of "denial" is something of a marker for severity of disorder.
People afflicted by disabling panic or depression may fully embrace the disease model. A diagnosis can restore a sense of wholeness by naming, and confining, an ailment. That mood disorders are common and largely treatable makes them more acceptable; to suffer them is painful but not strange.
In other words, in the clinical setting, the proliferation of diagnoses has diverse effects, making some people feel more normal, some less so, and touching others not at all. There is no automatic link between a label and a sense of abnormality.
Still, diagnosis can seem to confer stigma. I recall a patient, Roberta, who consulted me because her marriage was in trouble. Her husband resisted couples therapy. Might she see me alone?
In my office, Roberta was listless and slow of thought. Her memory was vague. Was the problem thyroid disease—or an occult cancer? Roberta willingly submitted to a workup by an internist. She was devastated when she was referred back for treatment of depression.
To Roberta, the mood disorder label confirmed her husband's complaint that something was wrong with her as a person. To be called depressed rather than, say, anemic constituted double jeopardy: She was in pain and she was flawed, in judgment and in character. She was unloved—and, now, abnormal.
Despite her misgivings, I asked Roberta to consider psychotherapy, exercise, bright lights (for winter in New England), and medication. I wanted her to be functioning well quickly, before she made irreversible decisions about her marriage.
The case had a memorable outcome. Only when she was better did Roberta reveal that at her low point she had contemplated suicide. Her summary comment was, "The fights with my husband saved my life." They caused her to be diagnosed—and treated.
When she first spoke with me, Roberta seemed to display normal sadness, that is, emotional disruption in the face of a life crisis. Psychiatry's critics are right: Roberta experienced the diagnosis as stigmatizing, and it led to her taking medication. But the case also illustrates why, for doctors, making diagnoses and educating patients about them is not a matter of choice; diagnosis can be lifesaving.
Just where does the impetus to expand diagnosis originate? A recent public flap highlights how categories proliferate. Raymond DiGiuseppe, a psychologist who researches anger, made headlines last spring when, at a scientific meeting, he argued that the DSM should add anger disorders, to parallel depression and anxiety disorders. There is a point at which anger becomes harmful, he contends. When scholars immerse themselves in an area—carefully observing research subjects, making note of differences and attendant harm—new sets of diagnosis seem obvious and inevitable. It doesn't matter whether treatment for the condition is medication or psychotherapy, or indeed, any treatment at all.
Clinicians respond to such academic findings often by focusing on the risk of harm. Their concern drives the expansion of diagnosis and, reciprocally, the contraction of the sphere of the normal. Research ranging from genetics to epidemiology, for example, now associates depressive episodes with harm to the brain, heart, blood vessels, hormonal glands, and bones—as well as to careers and marriages. The more closely researchers look, the more they find that risk attaches to even minor depressive episodes. Such evidence helps shape the diagnostic manual.
Critics of psychiatry complain that many patients fit no clear category and, at least on insurance forms, are given labels like "anxiety disorder not otherwise specified." Such patients nevertheless often remain at risk for an array of bad outcomes, studies indicate—findings that tend to broaden diagnostic categories.
Research technology is transforming understanding of mental disorders. New, more finely grained ways of looking at brains, neurons, and even cell connections, as well as powerful computer models, correlate many observed variations in function with disease and disability. The nerve connections you form, the neurotransmitters you elaborate, the symptoms you suffer—each may be linked to vulnerability to disorder.
One way psychiatry has responded to expansionist pressures is to turn to the concept of dimensions. Imagine compiling a list of all the factors ever associated with depression: irritability, a metallic taste in the mouth, a variant of a relevant gene, a change in size of a part of the brain. The list grows to 300 factors—symptoms, personality styles, gene variants, gene configurations, family histories, protein elaboration, and anatomical differences. Say, you rate a person on each of them.
Then you identify clusters of factors (extreme irritability, mild complaints of "off" taste, moderate levels of brain abnormality) that predict recurring episodes of mood disruption. A computer could identify varying degrees of severity for each of the hundreds of factors, with differing prognoses and treatment options. And then at some point, it becomes logical to dispense with the discrete, categorical have-it-or-don't-have-it view of depression.
In time, and in future manuals, dimensions may push categories aside. If for many of the factors, difference confers some degree of vulnerability to dysfunction, then we will find that we are all defective in one fashion or another. DSM-V may turn out to be conservative and postpone the inevitable, but it is hard to imagine a future in which abnormality is not much more prevalent than it is today. The shift in perception may become more marked as researchers identify subtle neuron- or gene-based variations with modest psychological consequences—increased risk for one or another condition—in the way that high blood pressure signals increased risk for stroke.
How will it feel to live in a culture in which few people are free of psychological defect? Well, we've been there before, and we can gain some clues from the past. The high-water mark for diagnosis occurred in the heyday of psychoanalysis. The Midtown Manhattan Study, the premier mental health survey of the 1950s, found that over 80 percent of respondents—more than triple our own abnormality rate—were not normal. "Only 18.5 percent of those investigated were 'free enough of emotional symptoms to be considered well,'" the New York Times reported. It even cited a psychiatrist who reasoned that, since health includes awareness of conflict, subjects who express no neurotic anxiety must also be abnormal.
In a forthcoming book, Perfectly Average: The Pursuit of Normality in Postwar America, American Studies scholar Anna Creadick reports that the U.S. hungered for a return to normality in the wake of World War II. Articles asking, "Is Your Child Normal?" appeared regularly in the press.
But being deemed neurotic was hardly a cause for distress. If anything, the affliction seemed to signal opposition to mass culture, as if emotional sensitivity were a protest against Eisenhower-era dullness and conformity. Popular essays and books such as The Man in the Gray Flannel Suit made normal men and women out as saps.
The lesson of mid-century is clear: When everyone is abnormal, diagnosis loses its sting. I suspect that we are entering a similar period in which diagnosis (or dimensional defect) spreads—while its gravity, in terms of social stigma, diminishes. Or else we will redefine normal to include broad ranges of difference.
To some degree, that is already happening. The deaf, anorexics, people with Asperger's syndrome—groups whose members might otherwise be considered impaired or deviant—have made vigorous claims to represent "the new normal." The Hearing Voices Network advocates liberation, not cure, for those who hallucinate. Where once people pursued normality through efforts at self-reform, now they proudly redraw the map to include themselves. In this context, diagnostic labels confer inclusion in a community. Today, an emotional or behavioral state can be understood both as a disorder and a unique perspective.
As the experience of mid-century shows, we can hold two forms of normality in mind—normal as free of defect, and normal as sharing the human condition, which always includes variation and vulnerability. We may be entering a similar period of dissociation, in which risk and pathology become separated from abnormality—or an era in which abnormality is universal and unremarkable.
We are used to the concept of medical shortcomings; we face disappointing realizations—that our triglyceride levels and our stress tolerance are not what we would wish. Normality may be a myth we have allowed ourselves to enjoy for decades, sacrificed now to the increasing recognition of differences. The awareness that we all bear flaws is humbling. But it could lead us to a new sense of inclusiveness and tolerance, recognition that imperfection is the condition of every life.—Peter Kramer
Albert Rizzi, 45, woke from a months-long coma brought on by meningitis and discovered he was blind. He didn't panic; events in the "'tween state" had somehow prepared him. It helped that his father told him, "Accept it; be the best blind person you can be." He did have to come to terms with a whole new way of living. "I look at my blindness as a characteristic. I focus on my ability. Disability is imposed on me," largely, he says, by society's fear of blindness. "There are technologies that allow us to do things. They tell me, for example, what color my clothes are. I'm angry they're not more available—and that businesses don't understand how able we are. The blind are great problem-solvers, for example, because we always have to assess our environment to keep from falling down stairs." What's normal? "I'm an overachiever; I want to believe I can do anything I want. I may have to do it differently, with more planning, but do it I will." Rizzi now runs his own educational organization, My Blind Spot—"because we all have blind spots."
Donna Flagg, 45, is founder and CEO of the Krysalis Group, New York-based business consultants whose motto is "Business NOT as usual." "Everything we do challenges the status quo," says Flagg, who early on—dyslexic and labeled retarded—was sensitized to looking at everything in novel ways. "Most people think there's only one way of doing things." The only time she ever struggled, she says, was in grades K-12. "Once I got out of the system, I was free; paths opened." Trained to be a dancer, she took a side job doing makeup at Chanel—and discovered she loved the business world. After starting her own beauty company, she opted for a second chance at school and got straight As on a master's degree at New York University. "I have two businesses, two master's degrees, I wrote a book. How do you call me disabled? What's not normal about what I've been able to do?" Flagg thinks "people confuse normal with average. Why would anyone want to be average?" She believes our society "creates a lot of things that don't fit." What makes her different, she insists, is that she has chosen not to work from a "platform of inadequacy."
Matt Kailey, 54, grew up female. Being an atheist in Christian Middle America—"there were parents who didn't want their kids playing with me"—was more of a "big deal" than the "gender thing" that surfaced at age 10 and waxed and waned thereafter. "I believed a mistake had been made and I was supposed to be male." Matt, né Jennifer, went on to become "very feminine"—high heels, makeup, big hair, breast implants. She dated males and married twice, drawn to men "that I wanted to be, not that I was attracted to. It was almost a vampirish thing; 'I'll suck the identity out of you'; not 'you add to me.'" He didn't know his feelings had a name until he was 40 and saw a therapist for other reasons. "I thought I was a normal female with one quirk." But once he learned about transsexualiity, he felt "compelled" to transition. His marriage broke up, and he "entered a whole new world of gays, lesbians, transsexuals." His attraction to men continued. "Gender identity disorder is in the DSM," he says. "I don't believe the transgendered are mentally ill. We have jobs, we shop, we eat, we pay taxes. We function. I consider myself normal. To me normal is whatever exists in nature."
Kathleen Fasanella, 48, was diagnosed with autism only 11 years ago, although from age 10 she "knew there was something different about me and my family." She could reel off all the zip codes in the U.S. She hated labels in clothes; they irritated her and she ripped them out. She dropped out of high school, but a lifelong sewer, she eventually studied pattern-making. "It's a hybrid of three types of engineering—product design and materials and industrial engineering." She has written manuals on starting a clothing manufacturing business and on pattern-making, but "I'm very dicey living on my own. I couldn't navigate all the executive functioning." She manages in business because "I have strategies" and "I control my own environment." She contends that "normal isn't what it's cracked up to be. Many 'normal' people seem abnormal to me. The fascination with celebrities is bizarre, to want to be like them. Normal people are obsessed with social conformity." Autistic people, she says, are more rational than "normal" people, more direct, less ambiguous, "less swayed by social trappings and presumed authority."