Diagnostic Cultures

A Cultural Approach to the Pathologization of Modern Life

Svend Brinkmann

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317151531
• Edition: 1
• Topic: Médecine
• Subtopic: Politique de santé

Some studies estimate that each year, around a quarter of the population of Western countries will suffer from at least one mental disorder. Should this be interpreted as evidence for the progress of psychiatry, a discipline that is now able to identify and treat mental illnesses that have always existed, or might it be the case that modern life somehow creates new conditions, or social pathologies? This book argues that in fact something more fundamental has been taking place in recent years: the development of diagnostic cultures. Taking account of the phenomenon of patients themselves 'pushing for' pathologization - and acknowledging therefore that this is not simply a case of psychiatry pursuing an agenda of 'medicalisation from above' - this volume examines the emerging trend towards interpreting our sufferings in terms of psychiatric conceptions and diagnostic categories. Drawing on new empirical case studies of psychological diagnoses, including depression and ADHD, and employing both cultural-psychological and sociological analyses, it charts the development of contemporary diagnostic cultures and asks whether, in transforming existential, moral and political concerns into individual psychiatric disorders, we risk losing sight of the larger historical and social forces that affect our lives. A ground-breaking examination of the shift towards the pathologization of suffering and the dangers that this presents to human self-understanding, Diagnostic Cultures will be of interest to scholars of social theory and philosophy, the sociology of culture, psychology and the sociology health and medicine.

Chapter 1

Introducing the Concept of Diagnostic Cultures

This chapter has two main purposes: first, I shall introduce the very idea of diagnostic cultures, which will be analyzed throughout the book, and second, I shall articulate the theoretical approach that will be used to analyze the phenomenon of diagnostic cultures. This approach is cultural psychology.

Living in Diagnostic Cultures

In one way, it should be quite easy to pinpoint the phenomenon of diagnostic cultures, because we (and when talking about “we”, I include everyone in the imagined hemisphere we call the West, but also elsewhere on the planet) live in and with these cultures in almost every arena of social life, whenever people experience problems or act in ways that are considered deviant. Formal psychiatric diagnoses are not as old as one might think. The first edition of the diagnostic manual published by the American Psychiatric Association, called the DSM,¹ appeared as late as 1952, and although diagnostic terms were of course used before this time, it was only from the second half of the 20th century that psychiatric diagnoses really spread from practices in clinics and hospitals to schools, welfare organizations, and families. Today, most of us can use diagnostic terms such as depression, anxiety, bipolar, ADHD, PTSD and OCD, and also semi-diagnoses such as stress, when we talk about the problems that we or our children face in everyday life. We read self-help books about how to manage various psychological afflictions that can perhaps be diagnosed, and consume novels and television series (e.g. The Sopranos) in which the heroes or villains suffer from diagnosable mental disorders. When we open our newspapers, we are routinely confronted with frightening statistics that tell us, for example, that the WHO expects that depression will become the second leading cause of global disability by 2020; we learn that up to one quarter of the population is mentally ill within any one year; and we witness how pharmaceuticals against symptoms of depression, anxiety and ADHD are prescribed to more and more people – children and adults alike. Even in Denmark – allegedly the happiest nation in the world – more than eight per cent of the population consumes antidepressants, and for some age cohorts (especially older people), the number is dramatically higher.

In what I call diagnostic cultures, psychiatric diagnoses are used by health professionals and lay people for many different purposes. Psychiatric terminology has been democratized and has travelled from the clinics and medical textbooks into popular culture (witness the example in Box 1.1).

Box 1.1 Mad or Normal? Psychiatric diagnoses as entertainment

In 2012 the national Danish Broadcasting Company aired the documentary “Mad or Normal?”² The idea was to challenge people’s biases about the mentally ill by showing that they are in most respects “just like you and me”. The show was run in an entertaining way, somewhat like a quiz, and hosted by a famous Danish “TV doctor”: three experts (one psychiatrist, one psychologist and one psychiatric nurse) were confronted with a group of ten people they had not met before, and five of these people had different psychiatric diagnoses (schizophrenia, eating disorder, OCD, social phobia and bipolar depression). Through the episodes, the experts were supposed to match the diagnoses with five of the participants. The viewers could also participate by voting on the internet, trying to guess which of the participants were mentally ill. In order to help the experts and also the viewers in this guessing game, the participants had to go through a number of trials that were supposed to provide clues as to who were ill and who were well. For example, they had to perform stand-up comedy in front of a live audience (the idea being that this would be difficult for someone with social phobia), and do a farm animal clean up task (possibly revealing the OCD sufferer). But in fact – and seemingly in line with the programme’s intentions – the experts could not guess who were ill, or which diagnoses belonged with whom. And the viewers were also quite poor at the guessing game.

What does a show like this tell us about diagnostic cultures and our complex attitudes to mental illness today? Initially, it can be observed that a show like this would have been quite unthinkable (at least in Denmark) just a few years ago. Psychiatric diagnoses were not publicly visible and would not be the centre of attention in a popular entertainment show on television. Superficially at least, this indicates that psychiatric problems are no longer taboo to the same extent and that stigmatization due to diagnoses has decreased. Furthermore, and in rather more subtle ways, the show points to a number of paradoxes inherent in the logics of the diagnostic cultures of the 21st century. For example, one powerful discourse, which is also mobilized in the television show, claims that psychiatric problems are illnesses “just like somatic illnesses”, as it is often said. In principle, there are no differences between somatic and psychiatric problems, and the two ought to be equal in the health care systems of the welfare state.³ At the same time, the underlying logic of the show seems to go against this discourse of “illness equality”. This can be seen if one imagines a similar show with people suffering from somatic illnesses. Would such a show be aired, with the participants having to go through trials that would bring forth their symptoms? This is very unlikely. Think of people with osteoporosis being forced to play hockey, for example, or diabetes patients eating loads of sweets. For some reason, it did not lead to public outcry (in fact quite the opposite) that people with mental disorders engaged in activities that were meant to disclose their illnesses. This reveals the contradictory understandings of psychiatric problems that we have in our diagnostic cultures: on the one hand, they are “just like somatic illnesses”, but, on the other, they are clearly implicitly thought of as something else.

Related to this point, it was noteworthy that the people with diagnoses in the programme were said to be “not ill” at the time when the show was made. For ethical reasons it seems reasonable, of course, to only enrol people who are not overly vulnerable, and as a form of protection against the tests in the show, but, given this, it is hardly surprising that the experts and viewers were unable to guess who were suffering from the various mental disorders. Also in the book, which accompanied the television show, we hear that Kirstine (diagnosed with OCD) “is now cured”, and she refers to her remaining problems as “bad habits, which everybody has” (Kyhn, 2012, p. 46). Again, to compare with somatic illness: if someone had once suffered a fracture, or had once had a tumour, but had since been cured, then no one would ever expect that people (not even experts) could come up with accurate guesses regarding these matters. So, although the programme meant to transmit the message that “they” are “just like us”, it paradoxically came to implicitly conclude that “once a psychiatric patient, always a psychiatric patient” – even if the symptoms have disappeared. The premise of the show was that it should be possible to guess the disorders even though the (former) patients were now symptom free, so, contrary to its surely good intentions, the show came to reinforce a discourse of chronicity concerning psychiatric problems. Again, we see the contradictory logics operating in diagnostic cultures: on the one hand, we define and identify mental disorders on the basis of symptoms (which is something I shall return to a number of times in this book), but, on the other, we hold the belief that such disorders may somehow persist even in the absence of manifest symptoms.

A couple of years later, in 2014, the show was followed up with two new episodes called “Mad or Normal? At the Job Interview” and, instead of mental health experts, three business managers were confronted with disguised psychiatric patients in a group of job applicants, and asked whom among the participants they would be interested in offering a job. Interestingly, the managers were very positive toward many of the people with diagnoses, and the “winner” was in fact a psychiatric patient. This second series, now thematizing psychiatric diagnoses and work life, demonstrates yet another paradoxical aspect of our diagnostic cultures: On the one hand, it is surely very positive that people who are diagnosed are considered “one of us” (which was the name of the accompanying national campaign to raise awareness about psychiatric disorders) to the extent that experts and business leaders cannot recognize them in a group of people. This can be seen as a demonstration that “they” are indeed “like us”. However, they are still “they”, and paradoxically identified as excluded through the diagnostic label. On the other hand, the argument or demonstration of just-like-us-ness can quickly be turned on its head to become a demonstration that if they are “just like us”, then why do they need special welfare benefits, pensions and other societally sanctioned advantages? The accompanying book asks the question directly: “If the three experts in the program are incapable of guessing who among the ten participants suffer from which disorders, then how on earth should the rest of us be capable of guessing it?” (Kyhn, 2012, p. 9). It might be a good thing in an ethical sense that viewers discover that psychiatric patients are nice people without dramatic problems, but the downside is that it might at the same time become difficult for patients to explain their sufferings and legitimize their need for help. This illustrates a broader dilemma concerning psychiatric diagnoses that will surface in various ways in this book: diagnoses may on the one hand be stigmatizing and pathologizing (and thus something one might wish to avoid), but, on the other hand, the labelling they provide can bring certain advantages in the diagnostic cultures of welfare states, which explains why some people actively seek to be diagnosed.

Box 1.1 is about psychiatric diagnoses as entertainment, or perhaps more accurately, “edutainment” aired on a respected public service television channel in Denmark, and it is meant to illustrate some of the ways in which diagnoses are conceived in contemporary society. From this little example, we have seen that a number of paradoxes are likely to emerge when dealing with psychiatric diagnoses today: (1) Through diagnoses, psychiatric problems are addressed as medical problems – and yet they are not just that; (2) Through diagnoses, psychiatric problems are equated with manifest and sometimes transient symptoms – and yet diagnoses have a tendency to reinforce chronicity; (3) Through diagnoses, psychiatric problems appear as “nothing special”, because many of us could be diagnosed at any given point in time – and yet normalizing the disorders may cause problems for people if this means that their problems cannot be recognized as sufficiently serious. There are indeed many paradoxes inherent in the logics of diagnostic cultures, which in itself might add to the suffering felt by those who live in these cultures and are diagnosed. Unsurprising, it is easier to explain one’s problem to oneself and others if it can be physically observed like a fracture or a tumour.

Expanding Diagnostics

The term “diagnostic cultures” is meant to point to the spread of diagnostic vocabulary and associated social practices to new areas of sociocultural life. But it is also meant to designate more concretely the increasing number of people, who are “living under the description” of a diagnosis (Martin, 2007). Today, we witness a diagnostic expansion in (at least) two ways: In many countries, more and more people receive a psychiatric diagnosis, and new diagnoses are continuously fabricated and suggested, some of which end up entering the official manuals (ICD and DSM), while others stay on the fringes of medical practice. In 1952, when DSM-I appeared, there were 106 diagnostic categories in a manual of 130 pages. In 1994, with DSM-IV, the number of diagnoses had increased to 297 in a manual of 886 pages (Williams, 2009). And now that DSM-5⁴ has been published, we see 15 new diagnoses (including hoarding and cannabis withdrawal), and elimination of a few others (most remarkably Asperger’s Syndrome). The number of official diagnoses thus increased dramatically in the latter half of the 20th century, but seems now to be slowing down.

In spite of the different changes, Rachel Cooper concludes in her recent book on DSM-5: “The most striking thing about the DSM-5 is how very similar it is to the DSM-IV” (Cooper, 2014, p. 60). This is particularly striking in light of the huge efforts that were put in to discussing and reconstructing the diagnostic system. Originally, the ambition while developing DSM-5 had been to instigate a paradigm shift equivalent to that which occurred in the transition from DSM-II to DSM-III in 1980. The transition in 1980 had implied a change from an etiological approach to diagnosis, with the doctor employing a holistic approach that took the patient’s entire biography into account, based in large parts on psychoanalytic theory, to a purely symptom-based approach to diagnosis in DSM-III. Horwitz has simply referred to this transition as one in which etiological psychiatry was replaced by “diagnostic psychiatry” (Horwitz, 2002). After DSM-III a diagnosis was (and is still) made by counting symptoms within a given period of time (e.g. two weeks). The change to DSM-5 was thought to imply a similar shift, only this time away from a categorical approach, where one either has or does not have a mental disorder based on the number and severity of symptoms, to a dimensional approach, where everyone can be placed somewhere on the continua. But the efforts to construct a dimensional system failed, and instead the chapters of the manual were reorganized. The similarity of the two editions of DSM – number IV and number 5 – means that many of the criticisms that were raised in response to DSM-IV (e.g. by Kutchins & Kirk, 1997) still pertain to DSM-5, and ironically are now voiced by people such as Allen Frances who were centrally placed when DSM-IV was created (Frances, 2013). (Frances was the chair of the DSM-IV task force.)

In addition to the rise in the number of people diagnosed, and also in the number of diagnoses that it is possible to give, there is according to some studies a third kind of rise, viz. in the number of people who ought to be given a psychiatric diagnosis, but who are currently not diagnosed. This is the problem of under-diagnosis, which co-exists with claims about over-diagnosis. Strictly speaking, these two tendencies can logically occur simultaneously if it is the case that ill people are not diagnosed and well people are diagnosed. The difference between the number of people who are diagnosed, and the number of people who ought to be diagnosed, is called the treatment gap, because a psychiatric diagnosis is in many societal contexts the obligatory passage point to treatment. According to authoritative estimates, the treatment gap for most mental disorders is more than 50 per cent (and for some, such as substance abuse, considerably higher), which means that more than half of those suffering from a mental disorder are not treated (Kohn, Saxena, Levav & Saraceno, 2004). References to the treatment gap can be used by patient organizations, researchers, professionals, and the medical industry to support the view that “more needs to be done” in finding and treating the mentally ill among us. The diagnoses are here central, because they define what mental illness is and how it should be found.

A good example of the discourse of expanding diagnostics can be found on the webpage of the World Health Organization,⁵ which states the following:

Lifetime prevalence rates for any kind of psychological disorder are higher than previously thought, are increasing in recent cohorts and affect nearly half the population.

Despite being common, mental illness is underdiagnosed by doctors. Less than half of those who meet diagnostic criteria for psychological disorders are identified by doctors.

Patients, too, appear reluctant to seek professional help. Only 2 in every 5 people experiencing a mood, anxiety or substance use disorder seeking (sic) assistance in the year of the onset of the disorder.

This is indeed a very dramatic message: the prevalence rates for any psychological disorder are higher than we thought and are rising – now affecting nearly half of us around the world! The disorders are underdiagnosed (cf. the treatment gap), in part because people do not seek help when they suffer. Seemingly, the prevalence rates are taken at face value, and the WHO does not even consider that one reason why people do not seek help can be because they do not feel they have a psychiatric problem – even when their problem meets the diagnostic criteria for a mental disorder. Needless to say, it can also be the case that people do not receive help, because no help is available (or is too expensive where they live), but the point is that there are likely to be many reasons for not being treated for what is allegedly a mental disorder.

The expanding diagnostics are seen around the world, but this book is almost exclusively about the so-called West, where half of the population is said to be mentally disordered in their lifetime and approximately a quarter of the population within any one year (Wittchen & Jacobi, 2005). In the West there are certain, quite fixed, ideas about what counts as mental disorder, as specified in the diagnostic manuals, and although the DSM (in particular) affects the local understandings of mental problems all over the world (Watters, 2010), there are still curious differences and exceptions. One such exception was reported in June 2014 in Nigeria, when Mubarak Bala was sent for psychiatric treatment because of a case of atheism. His disbelief in God was here interpreted as a mental disorder, likely an effect of schizophrenia, and he was detained against his will in a psychiatric ward. Fortunately, he has since been released, but is allegedly living in danger because of his (dis-)beliefs that were pathologized by the local doctors.⁶ This extreme example illustrates the variability in what counts as mental disorder and how psychiatry and larger cultural and political issues are intertwined. This is easy to see for Westerners when finding an extreme case in Nigeria, but it is much harder to notice in our own diagnostic cultures, given the way that the current conceptualizations of mental disorder are being naturalized through the diagnostic categories. That is to say, it has become hard for us Westerners to think of mental disorder outside what is made possible by the psychiatric categories. This means that the psychiatric-dia...