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?
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.
