Toward the end of my psychiatric residency, a friend pulled me aside to ask a question: Was he normal?
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?
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