The DSM, that bible of psychiatric diagnosing, has more in common with Vogue than is comfortable to admit. In a way, its editors are judges of mental health the way Tom Ford and Stella McCartney are judges of taste. And both enterprises are prone to producing fashion victims.
Jocelyn is a 44-year-old single interior designer who came to see me for presumed “bipolar type II.” She had seen the ads, done the online research, and self-diagnosed with a condition considered, even by DSM standards, “bipolar lite.” On my interview, Jocelyn was dressed in colorful clothes with big tribal jewelry and carefully applied, rather heavy makeup. Her hair was messy but in that studied way that implies the person spent a long time trying to put the perfect amount of disorder in it. One could say her appearance befitted her career of turning domestic space into art. She talked fast and interrupted me not infrequently, something she blamed on her “pressured speech,” a buzzword for bipolar, but that in her case could easily be attributed to her New York City upbringing. She got by on five to six hours of sleep a night, which is less than ideal, but which did not seem to affect her daytime productivity. She seemed to always be working on several projects simultaneously, but delivered them on time and with good feedback and many satisfied customers. She is curt, sometimes rude to her assistant, but that seemed more a function of a driven, impatient personality, rather than the pathological “irritability” of bipolar. Taken together, her symptoms did not in my opinion amount to bipolar disorder of any type, but that seemed to upset her.
She had, on the other hand, experienced in the past three periods of significantly low mood that were accompanied by significantly decreased sleep, appetite and concentration, along with a death wish. To me, those were clearly episodes of clinical depression, but of the “unipolar” kind that does not alternate with dangerously high, euphoric periods as we see in bipolar disorder. However, when I explained that to her, I almost had to take on an apologetic “I’m-sorry-but-you’re-only-unipolar” approach. Diagnosing her with unipolar depression felt “last season,” a faux pas on my part that seemed to stick her with an untrendy label.
For reasons as opaque as the return of eighties shoulder pads or seventies moustaches, psychiatric conditions go in and out of vogue, not necessarily because of any new research that proves a sudden increase or decrease in their real frequency. And so the last few years have brought us a huge wave of “multiple personality disorder” that gave way to a tsunami of “adult attention deficit disorder” that is now receding in favor of the latest must-have—“bipolar disorder” (of various types). It is impossible to fully understand why the culture (diagnosers and those seeking a diagnosis) latches on to any specific trend—the French got it right with their proverb Les gouts et les couleurs ne se discutent pas, or tastes and colors are not for discussion. But some forces are worth a conversation for they clearly play a role.
In psychiatry and medicine, as in the fashion industry, we are often manufacturing diagnoses that people don’t yet know they want. How these diagnoses are promoted to eventually become “brands” often involves sophisticated marketing strategies that seek to unleash desire in doctors and patients, in a manner similar to what Louis Vuitton might do to generate buzz around a new bag. You have seen the ads. The depressed woman is never shown googling suicide out of despair; the bipolar patient is never shown jumping off the roof because he thinks he can fly; and the attention-deficient child is never shown seriously wreaking havoc in the classroom. Instead, the protagonists are “like you and me,” boy/girl/child-next-door types who just seem to be having a bad day but who are somehow in need of expensive designer drugs with long lists of potential side effects (including suicide, psychotic mania and all manner of havoc). In their everyday appearance that is nonetheless linked to severe diagnoses and powerful medications, these actors are poster children for the current drive to pathologize the normal, to make illness the new default and new baseline. “If they need an antipsychotic, I must, too!” Pharmaceutical companies spend more money advertising their products than carrying out research, which goes some distance in explaining how a sometimes under-studied diagnosis can become a cultural meme. In a sick way, we have made it fashionable to be ill. For millennia, people have blindly followed clothing trends. We now have a similar relationship with our health and psyche—“Low T” or “gluten sensitivity,” anyone? With certain popular diagnoses, the relief is twofold once we acquire them: We have an explanation for vague existential discomfort and that explanation makes us fashionable, because everybody else seems to have it. What's not to like?