Mental illness stigma comes from many places and in many forms. Stigma often invalidates the experience of those of us with mental illness, and one of the ways this can happen is through pathologizing normalcy. By this I mean inflating the significance of “normal” emotions and minimizing the significance of mental illness to make it seems as though they’re on par with each other. Some of this comes from the language we use. “Anxiety” and “depression” are often used to describe “normal” human emotions, but the same words are also used to describe psychiatric disorders. This distinction is not always apparent to people with limited knowledge about mental illness, which is where misinterpretations come in. People may think that because they feel “anxious” or “depressed” emotionally and those feelings are uncomfortable, then they likely have a mental health disorder. Conversely, people with an anxiety disorder or a depressive disorder may be dismissed as just overinflating “normal” emotions.
I got thinking about this issue after watching a documentary called The Age of Anxiety, which was aired on Doc Zone on CBC, Canada’s public broadcaster (it can be viewed online here, but only in Canada unfortunately). According to the producer, “The medical definition of what constitutes an anxiety disorder is expanding to include so many aspects of normal human behaviour that we’re in danger of turning half the population into psychiatric patients.”
One woman featured in the documentary appeared to have high levels of neuroticism (I use that in a psychological rather than a pejorative sense). She was shown hosting some friends for what was essentially a DSM self-diagnosis dinner party. At the end of their discussion, they concluded that all of them, and probably most people in general, “meet the threshold” for an anxiety disorder.
The DSM, the “bible” of psychiatry, was never intended to be a paint-by-numbers self-diagnosis tool. Someone might think check, check, check, I meet all the criteria for this disorder, but there’s an important piece that’s very easy to overlook. In the DSM-5, criterion D for diagnosing generalized anxiety disorder is: “The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” That “clinically significant distress” is where clinical judgment is called on to distinguish between “normal” and “disorder” when it comes to things like anxiety and depression.
That boundary between normal and disorder can appear murky or even non-existant if people don’t have good information and haven’t seen the devastation that mental illness can cause. Without a frame of reference, it’s easy to start making uneducated guesses about what constitutes a disorder. A medical historian interviewed for the documentary suggested that if your problem can be corrected by a new boyfriend or a cheque for $5000, you probably don’t have a psychiatric disorder. Simplistic, yes, but still a good point. What is not helpful is when medical professionals contribute to the blurring of boundaries. A psychiatrist interviewed for the film speculated that “by age 32, 50% of the population might qualify for an anxiety disorder”. If it’s uninformed people doing the diagnosing, perhaps, but not if it’s a skilled clinician.
The documentary described the ethically questionable marketing campaign run by the pharmaceutical giant GlaxoSmithKline promoting social anxiety disorder as a common problem that could be managed with Paxil. This led the filmmakers to conclude that social anxiety is essentially a made-up condition for the purpose of selling drugs. Just because a drug company is pathologizing “normal” levels of “anxiety” in social situations does not in any way mean there aren’t people who truly have crippling social anxiety disorder, and I think it’s irresponsible when people suggest that this is the case.
The DSM has been a frequent target for criticism when it comes to pathologizing normalcy. In some cases this has very much been warranted, with homosexuality being a prime example of this. But that’s not always as much of an issue as it might appear. One of the concerns often expressed when the DSM-5 came out was the removal of grief as an exclusion criteria for diagnosing a major depressive episode, as some thought that this would end up pathologizing “normal” grieving. Yet the DSM-5 specifically addresses and cautions against this, stating that the purpose of the change was not to diagnose grief as depression, but rather to recognize that for some people grief may precipitate a major depressive episode. Again we run into the problem that if depression is thought to be a sham diagnosis for grieving, this is likely to contribute to stigma that invalidates the experience of people who genuinely have a mood disorder.
If people are in fact being overdiagnosed with anxiety and depression, I suspect a major contributing factor is how doctors get paid for their time. Billing is typically done using diagnostic codes. General practitioners don’t get paid to do a lengthy psychiatric assessment, so they’re often not getting the history needed to make a solid diagnosis.
The documentary observed that more and more people are turning to medications to manage “anxiety” over everyday issues, and general practitioners are handing them out like candy. I think insurance coverage has something to do with this; many people are more likely to have coverage for medications than psychotherapy. I find it really interesting that within the mental illness community there are a fair number of people who are really uncomfortable with medication, but among the “worried well” it seems that medications may be seen as a quick and easy fix.
A pharmacy technician who was interviewed speculated that “about 3/4 of what we have [in the pharmacy] is for anxiety”, and the pharmacist working with her added “these things are all for situational anxiety, situational depression”. I’m glad I don’t go to that pharmacy! If society gets the idea that anti-anxiety and antidepressant medications are doled out like candy, how likely are they to take it seriously when some of us truly need medication to manage our illnesses?
There’s a lot of work still to be done in the fight against stigma, and education is a huge part of that, which means that it’s important for us to keep writing, raising our voices, and sharing our stories.