How do we decide what emotions, thoughts and behaviours are normal, abnormal or pathological?
This is essentially what a select group of psychiatrists decide each time they revise the Diagnostic and Statistical Manual of Mental Disorders (DSM), a bible for mental health professionals worldwide.
Questions like these are unavoidable and cannot be answered by science alone. This point was famously demonstrated when homosexuality was declassified as a mental illness in the DSM in 1973 by a simple vote.
The DSM was first published by the American Psychiatric Association in 1952 to create a common language and standard criteria for the way we classify mental disorders. It’s now used around the world by clinicians, researchers, insurance and pharmaceutical companies, the legal system, health regulators and policy makers, to name a few.
Now in its fifth edition, revisions have gradually expanded the number of mental disorders, while also removing some as understanding or values change. Over the years many of these amendments have courted controversy.
These days, criticisms of the DSM are that it medicalises normal behaviour such as fidgetiness, noisiness and shyness.
Currently, three temper tantrums a week, negativity, irritability and anger would qualify a child to be labelled with disruptive mood dysregulation disorder. The label assumes first that the child is suffering from a problem, and second that the problem is pathological. Yet one may also question why it is the child who must be labelled and not the parents. For example, why do we not have a diagnosis called inability to discipline one’s child disorder?
What the “problem” is and who is judged to be the party “suffering” from it are value judgments which carry with them the cultural biases and assumptions of the individuals making those judgments. If we don’t examine value judgments properly, we risk making judgments that are discriminatory or harmful.
For example, although hysteria has now disappeared from official psychiatric diagnosis, there are elements of it present within other psychiatric diagnoses, most notably premenstrual dysphoric disorder (PMDD).
Commonly described as a more severe form of premenstrual stress (PMS), PMDD has been accused of labelling as a mental disorder normal and understandable reactions to the sort of stressful circumstances that disproportionately affect women in a modern society that still has not achieved gender equality.
In this way, psychiatric diagnosis could act as a way of brushing aside indicators of social injustices.
Likewise, sadness and changes in sleep, eating and so on can be normal and understandable reactions to loss (e.g. in the case of bereavement), not necessarily indicators of mental illness. In fact, behaviours like these can act as a positive sign that something is wrong, functioning as a catalyst for changing one’s situation for the better.
But the DSM only focuses on these “symptoms” and does not take into account the individual’s context. This in itself is a value judgment.
This is why our process of classifying mental illnesses should involve experts for whom examining value judgments is their bread and butter – philosophers. Bioethicists and philosophers of psychiatry are trained in bringing value judgments to light and analysing them in depth.
The way we classify mental illnesses also has broad implications for those diagnosed and for society – something that sociologists would be well placed to consider.
We could make good use of these experts by requiring each revision of the DSM to pass through an ethics assessment by an independent panel made up of philosophers, sociologists and ethicists.
Philosophers could identify and deliberate the value issues, sociologists could present the possible social consequences of proposed changes, and ethicists could make the complex harm/benefit analyses and ethical trade-offs that will inevitably be involved.
The panel also needs to have “teeth”, so it should have the power to veto or modify a category.
This might sound like a provocative proposal, but it is similar to the procedure we already have for scientific studies. Just as these studies must gain ethics approval before they go ahead in order to mitigate harm to participants and the community, having an ethics review panel would be an extra step of “checks and balances” for the DSM.
While those involved in making the DSM come from a variety of backgrounds – primarily psychiatrists, psychologists, social workers and clinicians – none have been primarily ethicists or philosophers.
And while some psychiatrists might have the training and experience that enables them to examine value judgments, it would be unreasonable to expect that to be the case, just as it would be unreasonable to expect ethicists and philosophers to be able to evaluate scientific judgments.
The solution I propose is based on the idea that psychiatric diagnosis should serve an ethical purpose – relieving certain forms of suffering and disease.
In light of this ethical purpose, we must do our utmost to consider value judgments that can cloud our view of “illness” and how it should be treated. I believe establishing an ethics review panel for the DSM can go a significant way towards achieving that goal.