When Normal Feelings Get Called Illness

In recent days, various media outlets have widely reposted the story of the Mirror concert incident, urging members of the public who suspect they may have PTSD to seek professional help as soon as possible. Precisely because information now circulates so freely, it is easy to find online the symptoms and descriptions of psychological disorders, and the public is quicker and more casual about slapping a "diagnosed with XXX" label on themselves or on others. Sometimes, once people are too quick to treat negative emotions as a psychological illness, ordinary individuals end up stigmatised, medical resources are wasted, and those who genuinely need help are not served — clearly not a healthy social phenomenon. The book 《Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatry》 was written by Allen Frances – professor of psychiatry at Duke University in the United States and chair of the task force that drafted the 《Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)》 — and it squarely examines the phenomenon of "Diagnostic Inflation".

1. Who has the authority to define the symptoms of a mood disorder? "Diagnostic Inflation" 

The author points out that over the past few decades, both general practitioners and psychiatrists have leaned too heavily on the DSM as their diagnostic standard, leading doctors to frequently misdiagnose mental illness, over-diagnose, prescribe inappropriately (even dangerously), or carry out unnecessary treatment — a phenomenon known as diagnostic inflation. Beyond "stigmatising (stigmatization)" the person concerned and affecting their later daily academic / social / working life, it also drives up medical costs and leads to an uneven distribution of society's medical resources. More importantly, over-diagnosis means that the ordinary emotional highs and lows that normal people go through are more easily judged by "experts" to be "Psychopathology", while a person's own capacity to recover and their resilience in overcoming life's challenges are overlooked. With the arrival of the DSM-V, the definitions of most mental disorders changed and the threshold for diagnosis was lowered relatively. As a result, even without a diagnosis from a professional, "normal people" are being classified as "people with a mental illness", and the line between "normal" and "abnormal" has gradually grown blurry too.

2. What exactly is "normal" and "abnormal"? 

Although the definitions of "normal" and "abnormal" may seem self-evident, to this day there is still no concrete, clear boundary that distinguishes the two.

For example, we can use statistics to assess a particular trait in a person — such as IQ, a depression index, and so on — that is, their position within the population's normal distribution; yet that cannot tell us at which point on the normal distribution someone should be defined as "abnormal" or "supernormal". Why must one have at least five clinical symptoms (rather than more or fewer) before (according to the DSM-V) the person concerned can be defined as a depression sufferer?

In terms of neuroscience, because the connections and information transmission among the billions of neurons in each person's brain are utterly unique, neuroscientists have so far been unable to observe, measure or identify any single neuron or group of neurons as a marker for the appearance of a particular mental illness.

In terms of philosophy, there is no moral "golden rule" to teach us how to define "correct" and "incorrect", "normal" and "abnormal". In terms of linguistics, "normal" is defined as the absence of "abnormal" and vice versa, but at the same time this method of definition falls into the logical fallacy of a circular argument (circular argument). 

"Normal" is an elusive concept, and the process of defining "normal" and mental illness inevitably involves a degree of subjective judgement on the part of practitioners (doctors in particular).

3. The hidden factors in defining "normal" and "abnormal" 

(1) Conflicts of interest

Including commission payouts from pharmaceutical companies (such as prescribing a drug to a set number of patients of a particular category as specified by the pharmaceutical company, and other forms of subsidy from pharmaceutical companies); 

(2) Academic background and training

For example, doctors who trained under a mentor specialising in the clinical supervision of mood disorders are, later on, also more inclined to make mood-disorder-related diagnoses (rather than other mental disorders) for their patients; 

(3) "Diagnostic trends"

For example, several decades ago about one in every two thousand adults had autism, but as the public (including doctors and psychologists) gradually became aware of the link between social barriers, rigid thinking and behaviour, and autism, data from Hong Kong in recent years shows that roughly one in every sixty-eight schoolchildren has autism.

Is the "toxicity" of the environment in which humanity now lives stronger than before, so that we are more prone to mental illness? (Here it is worth adding a point: some scientists believe that the life stress faced by our ancestors in their environment was in fact no less than that of present-day humans — for instance, they had to face attacks and invasions from wild beasts or other tribes at any moment.) 

Or is it that we, along with doctors and psychologists, all over-rely on the DSM or other diagnostic manuals, treating them as "the word of God", with each stakeholder interpreting them as they please?

Looking at it from another, deeper angle: is it the case that today we are gradually no longer able to embrace people's diversity (individual difference), and that our tolerance for the uncertainties of life and the shifting tides of thought and emotion is now a far cry from what it once was? Throughout our lives we will encounter all kinds of people and events, accompanied by partings and reunions, joy and anger, sorrow and delight. For example, the author points out that psychologists and doctors may classify a person's "relatively" unpleasant experiences as a "depressive episode", which is a component of depression, prompting them to be quicker to diagnose the person as a depression sufferer. Some psychologists and doctors will even tend to likewise define the "relatively" happy parts of a person's experience as a "manic episode", thereby declaring that, because the person simultaneously shows a "depressive episode" and a "manic episode", they are — inaptly — crowned a sufferer of "manic-depressive depression/bipolar disorder (bipolar disorder)". In terms of drug treatment, depression sufferers are usually prescribed antidepressants with lower side effects; however, once diagnosed with "manic-depressive depression/bipolar disorder", they may need to be prescribed drugs with more serious side effects, bearing unnecessary risk.

The above are the arguments the author sets out based on the situation in the West. Of course, the circumstances described above may not apply entirely to Hong Kong. Nonetheless, although the author of this piece is not a doctor and is in no position to challenge a doctor's judgement, the wish remains to point out that misdiagnosis, over-diagnosis, inappropriate prescribing, and being too quick to label someone as ill are, in fact, of no benefit. Humans have a tendency to sort things into categories and labels; viewed from an evolutionary perspective (evolutionary perspective), this can increase predictability and reduce uncertainty, but the tendency is at the same time a double-edged sword, because we may end up labelling some perfectly normal negative reactions as illness. 

Take this Mirror concert incident as an example: we feel negative emotions such as shock and anger because we cannot accept that the safety of Hong Kong's performers could be so lacking in protection. Faced with extraordinary circumstances, having a strong reaction is entirely reasonable and normal, and does not necessarily mean one has a psychological disorder.

In this age of diagnostic inflation, beyond the need for practitioners to be careful with their diagnoses, the public should also avoid labelling negative emotions too early. This is not about telling you to ignore the existence of negative emotions, but rather that there is no need to pathologise them. You can seek out methods to help process emotions: on one hand, you can confide in those around you, and try mindfulness and exercise.