Diagnostic Criteria Neurobiology

Is Your Client Mentally Ill or Just Having a Tough Time?

As awareness of mental illness increases, we must ask: are we helping our clients by diagnosing more “mental disorders” or are we over-pathologising and harming them?

By Mental Health Academy 2024-07-08 05:07:43

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As awareness of mental illness increases, we must ask: are we helping our clients by diagnosing more “mental disorders” or are we over-pathologising and harming them?

Related articles: Why Mental Health is Not the Opposite of Mental Illness, Why Mental Health Literacy Matters, Rethinking Wellness: A Holistic Perspective on Health.

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Introduction

Awareness of mental health issues in the general population has dramatically increased in recent decades, encouraging greater dialogue, reducing stigmatisation, and demanding an increase in the resources of both attention and funding. The DSM (Diagnostic and Statistical Manual of Mental Disorders) began to catalogue types of mental unwellness in 1952, with the first version citing 106 disorders. The fourth edition (the DSM-IV), published just 45 years later in 1997, listed 297. The DSM-5, published in 2013, boasted 313 (Sutton, 2020). Has the global general population become nearly three times more “mentally ill” in just over a half century, or is something else going on?

In this article we review the debate around how we, as mental health professionals, can strike a balance between elevating mental health awareness (in ourselves, in our clients, and in the general population) and over-medicalising, or over-pathologising, conditions which arise as part of the normal human experience or from adverse early environments. We examine various phenomena contributing to the rise in awareness and number of problems deemed pathological, looking at both the advantages gained by diagnosing more and more experiences as disorders and also the unintended consequences of doing so. Is a new way of thinking needed, we ask, and if so, what might that look like?

A diagnosis for most things: How did we get here?

A dozen years ago, the World Psychiatry journal published an article reflecting on how psychiatry has had an evolving target. True, it noted, the task of the psychiatric profession is still to deal with people who are “mad”. But, it continued, the actual “target” of the profession has changed dramatically in recent decades, becoming a range of mental disorders (now called “mental health problems” in some international organisations’ official documents), including numerous conditions which are not binary (that is: you either have it or you don’t), but are on a continuum with normality. Deciding where the boundary is between normal and pathological has become increasingly problematic. Determining the boundary on pragmatic grounds or on the basis of “clinical utility” seems to imply, said the journal, that a condition becomes a mental disorder when there is an effective treatment available for it (Maj, 2012).

Opposite pressures

On the one hand, psychiatrists are being accused of pathologising ordinary life (whether in good faith, unconsciously, or in “bad faith”, so that they can expand their influence). On the other hand, the psychiatric profession receives pressure to go beyond the diagnosis and management of mental disorders, attempting to promote mental health in the general population. Especially in countries with developed mental health services, psychiatrists are answering the call to treat “mental health problems” – not proper mental disorders – to reduce distress brought on by events such as natural disasters and economic crises. Moreover, such professionals are increasingly pressured to diagnose and manage mental health disorders as early as possible, meaning that they are dealing with “precursors” or “prodromes”  of those disorders with the inevitable consequence of pathologising conditions that are (still) within the range of normality (Maj, 2012).

Beyond that, in some health systems, well-meaning health professionals such as counsellors and psychologists search for diagnoses with which to label their distressed clients so that the clients can receive treatment through the public (and much more affordable) healthcare system.

We’re all “traumatised”: social media talk changing clinical presentation

A study last year by the University of Melbourne (Wisbey, 2023) has shown that today’s frequent, casualised way of talking about mental health has changed the way patients are presenting in clinical practice. Terms such as “anxiety” and “depression” are now relentlessly shared and colloquially discussed, in everyday conversations and on social media. So, if we’re down for a few hours about, say, some news we received today, we might exclaim, “I’m so depressed about this!”, whereas the DSM tells us that major depressive disorder means being depressed most of the day for at least two weeks. Similarly, how many of us have told someone who is tidy, liking their things arranged in a particular way, “You’re so OCD [obsessive-compulsive disorder]!”? The researchers particularly noted the increasingly wide application of the term “trauma”. Where it used to apply to a life-threatening event experienced or heard about, we now tend to refer to almost any adversity (think: getting scolded by the boss or stopped by police for speeding) as “traumatising”. Labels, say the researchers, are disempowering individuals and are potentially damaging.

As part of the review, the investigation examined abstracts of more than 800,000 psychology articles published between 1970 and 2018, together with 500 million words from everyday American English, including television shows, fiction, newspapers, and spoken language. And the finding? That the concepts of anxiety and depression have broadened, intensified, and pathologised, all at the same time. The researchers noted that, while anxiety and depression can be transient mood states (even functional, given some circumstances), they are increasingly being cast as disorders, with the result that people are more inclined now to present to a mental health professional claiming to have anxiety and/or depression. The results of that, in addition to people stigmatising themselves, may be that there is excessive treatment-seeking, usurping spaces in busy counselling practices that genuinely mentally disordered people could have taken up (Wisbey, 2023).

Dr. Google’s practice is busy

The above trends have been amplified by the role of the internet in facilitating the growing trend of self-diagnosis. The vast wealth of information available on the internet empowers individuals to educate themselves about mental health conditions, including their symptoms and available treatments. There is a sense of relief and validation in getting a name for what one is experiencing, plus people can gain a framework for understanding distressing experiences that might otherwise feel overwhelming. Moreover, internet articles are not generally shy of suggesting a path toward treatment and, certainly, the importance of initiating conversations about mental health with their doctor. All that is good.

Where visits to Dr. Google begin to be problematic is in the tendency toward confirmation bias, as well as the over-pathologising of normal emotional responses (like being sad when one is freshly grieving the loss of a dear one). When individuals begin to perceive their emotional, psychological, and behavioural responses only through a medical lens, the upside may be a validating, structured approach to treatment. The downside, however, is seen if people succumb to the temptation to blame a “disorder” for their actions or feelings, rather than confronting the underlying issues that have given rise to the symptoms; avoidance and disavowal are rife. Too, self-diagnosis can be wrong, resulting in delayed or inappropriate treatment (Ng, 2023).

The rise of digital mental health platforms

Do you feel anxious today? Depressed? There’s an app for that. As mental health literacy has grown, tech entrepreneurs have exploited the opportunity to create digital mental health platforms – apps and websites – that offer self-screening and, sometimes, techniques to overcome the “problem”. But the digital platforms have also likely encouraged a culture of seeing normal, everyday fluctuations in mood, etc., through the lens of pathology. With such easy access to these tools, it’s natural that we come to blur the line between normal psychological variation and disorder. So which came first: the pathologising of our normal human experience, opening the door to such platforms, or the creation of such platforms, engendering more pathologising? The answer is not clear, but what does stand out is that these two phenomena are intertwined with each other in today’s mental health landscape (Ng, 2023).

10-minute medicine

OECD Indicators and the World Health Organization reported an escalated prevalence of “mental illness” in Australia, Britain, and the United States, with 18-25% of their populations now said to be afflicted with a mental disorder (OECD, 2017; WHO, 2018). The Australian Institute of Health and Wellness, meanwhile, noted that 12.4% of all general practice encounters are mental health related, with psychological issues cited as the most common reason for patient presentation for the past six years. The Australian Bureau of Statistics data reveal that 44% of all Australians between 16 and 85 have experienced mental health issues at some time in their life, with anxiety disorders being the most common (Wisbey, 2023). Anti-depressant medication utilisation in Australia trebled between 1990 and 1998 and has continued to increase (Ashfield, 2018). Again, we ask: do these statistics of apparently increasing prevalence mean that people are becoming more unwell, or is something else happening? Dr. John Ashfield does not see a crisis of mental health, but a “systematic medicalisation of common human experience.”

He argues that, while allopathic medicine for physical health (the endeavour of detecting, understanding, diagnosing, and treating  problems) has shown itself to be of “remarkable merit”, the same approach, when applied to mental health has had limited benefits. For start, he observes that the highly complex individuality of psychological experience cannot be “shoehorned” into static psychopathological illness categories. Doing so means reducing the human being from a person of uniqueness and complexity – a self-acting agent adapting to a demanding world – to merely “an organism”. The twin phenomena of the lowering of diagnostic thresholds by the DSM along with ever-increasing pressure on G.P.s means that doctors are forced to do “10-minute medicine”: a short consultation during which there is insufficient time to contextualise or appreciate the complexity of patients’ psychological distress, let alone offer a useful diagnosis or treatment suggestion (Ashfield, 2018).

But they need to do something; their profession – and the patient – expect it. In fact, as noted above, patients cannot get the many subsidised services and treatments without a diagnosis. Yet, with burgeoning self-diagnoses of “illness”, such services often have a long waiting list. So, medications are often prescribed, supplied by the ever-expanding pharmaceutical companies with a pill for nearly every malady. Medicalising human distress in such ways has deeply negative implications, not only for the mental health consumers deemed “mentally ill”, but also for the functionality of the whole health system. The estimated cost of mental ill health to Australia, for example, is about $4,000 per year for every tax payer (Ashfield, 2018). And modern medicine continues its grim march toward defining ever-broader aspects of our human experience as pathological. What is the solution?

Introducing the Neuroplastic Narrative

Last year, Frontiers in Psychology published an article by Hayley Peckham (2023) outlining a non-pathologising biological foundation for trauma-informed and adverse childhood experience-aware approaches. Observing that most people accessing mental health services have adverse childhood experiences and/or a history of complex trauma, Peckham salutes the calls to move from medical model approaches to trauma-informed ones. The difference here is that the latter prioritise the impact of life experience over underlying pathology in establishing the aetiology of emotional and psychological suffering. Trauma-informed approaches throw out the question of “What is wrong with you?” and substitute instead, “What happened to you?”: a stance which profoundly understands that human behaviours are an attempt to adapt to the environment.

Unfortunately, some individuals are born or come into hostile, non-growth-inducing environments, where resources are limited and of uncertain duration; thus, survival is best ensured via fast reproduction (in case it won’t be possible later) and “living in the moment”: immediate gratification. Conversely, those lucky to be born into or living in benign environments where survival is ensured can entertain a goal of thriving: delaying reproduction until a more optimal time, planning and organising for a bright future by doing “hard yards” now and delaying gratification.

Converting those life history trajectories into behaviours, we can see how, almost always, clients’ behavioural responses are actually successful adaptations to a hostile early environment; they thus exemplify resilience, not illness. Think here of the woman born into poverty, a violent family, and/or a situation of racial discrimination or sexual or other abuse. Having multiple, early sexual partners and possibly becoming pregnant, leaving school early, or using substances to escape from the dreary conditions makes sense; it’s just that those adaptations engender despair, depression, and anxiety, which we then call “pathological”, deeming the person to be mentally unwell.

Conversely, a child born into a loving family with broad resources at their disposal is free to delay having children, become emotionally regulated, and attend long years of education to prepare for a well-resourced future. Such a child can more easily thrive. Adapting to a benevolent environment does not lead a person to dangerous “survival” behaviours.

Peckham’s neuroscientific point is that human beings have various neuroplastic mechanisms we have collectively evolved – such as epigenetics, neurogenesis, synaptic plasticity, and white matter plasticity – which allow us to learn from and adapt to our environment. The Neuroplastic Narrative prioritises lived experience and recognises that our experiences become embedded in our biology through these evolved mechanisms that ultimately act to preserve survival in the service of reproduction. Neuroplasticity refers to the capacity of neural systems to adapt and change, and the above mechanisms allow us to learn from, and adapt to, past experiences. This learning and adaptation in turn allows us to better anticipate and physiologically prepare for future experiences that (nature assumes) are likely to occur, based on past experiences.

The problem for mental health and “illness”, however, is that neuroplastic mechanisms cannot discriminate between experiences; they function to embed experience regardless of the quality of that experience, generating vicious or virtuous cycles of psychobiological anticipation, to help us survive or thrive in futures that resemble our privileged or traumatic pasts. The aetiology of suffering that arises from this process is not a pathology (a healthy brain is a brain that can adapt to experience) but is the evolutionary cost of surviving traumatising environments.

Thus, concludes Peckham, misidentifying this suffering as a pathology and responding with diagnosis and medication is not trauma-informed and may cause iatrogenic (health provider-induced) harm, in part through perpetuating stigma and exacerbating the shame which attends complex trauma and ACEs.

As an alternative, Peckham introduces the Neuroplastic Narrative, which is situated within an evolutionary framework. The Neuroplastic Narrative – complementing both Life History and Attachment Theory –  provides a non-pathologising, biological foundation for trauma-informed and Adverse Childhood Experience-aware approaches (Peckham, 2023).

Conclusion

Standing back from the details of the Neuroplastic Narrative approach, we can observe how such paradigmatic changes in thinking can help us shift from seeing most emotional responses to life’s upsets as pathology. Letting in new neuroscientific understandings about how the brain works can allow us to see mental health challenges from a more compassionate, less judgmental stance. It is a position which understands how attitudes and behaviours that we currently diagnose as mental illness are more rightly seen as adaptive responses to (present) tough times or (past) harsh, harm-generating environments. And the insights gleaned from that can be the start of a radical overhauling of our notions of mental health and illness, at base, and the healthcare systems that spring from them.

Editor’s note: Learn more about the intersection of neuroscience and clinical practice with the MHA Micro-Credential, Clinical Applications of Neuroscience. Led by Professor Chad Luke, Ph.D., this 45-hour course will help you to make sense of both the possibilities and the pitfalls of integrating neuroscience into mental health care.

Key takeaways

  • Increasing aspects of normal human experience are being deemed “pathological” and increasing numbers of people are claiming to be anxious, depressed, or otherwise mentally unwell.
  • Pressures on health professionals and health systems in general, the increase in mental health literacy and discussion of mental health issues on social media and in conversations, and the rise of self-diagnosis via internet websites and apps have all created a situation of greater pathologising of mental and emotional conditions: a situation which has aided the awareness of mental health issues but also engendered harm.
  • Most people accessing mental health services have adverse childhood experiences and/or a history of complex trauma. Asking “What happened to you?” instead of “What is wrong with you?” can create a powerful shift towards understanding how human behaviours are attempts to adapt to the environment.
  • An alternative to seeing ever-larger swathes of human experience as “pathological” is to work from the stance of the Neuroplastic Narrative, a non-pathologising biological foundation for trauma-informed and adverse childhood experience-aware approaches.

References

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