Recently, a student asked me for an extension on a paper, informing me that her anxiety and depression had been acting up making it difficult to concentrate on her work. I try to be sympathetic to the mental wellbeing of my students, so I granted the extension. But the way she talked about her anxiety and depression I found troubling.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), one does not merit the diagnosis "depression" unless one has been experiencing the symptoms of depression most every day for at least two consecutive weeks. We call this condition "chronic depression" for a reason. It is not episodic. People with depression generally struggle with depressive symptoms chronically for an extended period of time.
My student, however, right up until the time she asked for the extension, showed few signs of depression. She was attending class regularly, engaging in the class discussions, engaging with her peers, and smiling and laughing just like everyone else. Of course, people can hide their pain, but truly depressed people normally exhibit significant behavioral changes too. In addition, the language she used—"my anxiety and depression have been acting up recently"—seems not to fit with the DSM criteria. Depression is not something that "acts up" from time to time like arthritis. It is chronic.
I think my student is the victim of diagnostic inflation. Diagnostic inflation refers to the tendency of the medical establishment to expand diagnostic criteria for certain diseases, allowing more people to be labeled with a particular diagnosis. This then has profound effects on the kind of medical treatment they receive. If the criteria for "normal" blood pressure are lowered, for example, more people will be diagnosed with hypertension and prescribed a blood pressure medication.
Diagnostic inflation has been especially pernicious in the mental health field because there are no medical tests diagnostic of any mental illness. Mental illnesses are diagnosed purely on the subjective reporting of the patient’s feelings and changes in their behavior observed by those around them. The very subjective nature of mental health diagnosis allows then for the expansion of diagnostic criteria unchecked by the results of actual medical tests. And the mental health industry along with the pharmaceutical industry has employed this power with abandon.
The first edition of the DSM published in 1952 described 128 discreet mental illness categories and was 132 pages long. The current fifth edition, published in 2013, describes more than 500 categories and is 947 pages long! Are we really to believe that psychiatrists have "discovered" hundreds of new mental illnesses in the last sixty years? Of course not. Diagnostic inflation has instead systematically pathologized ever larger aspects of normal human emotional experience.
For example, every version of the DSM up through the fourth edition carried a grief exclusion in its description of major depression. That is, if a person exhibited the symptoms of depression, but it could be determined that those symptoms occurred in response to a major emotional loss, like the death of a loved one, then the person should not be diagnosed with depression. They are instead experiencing the normal human reaction of grief. But in DSM-5, the grief exclusion was eliminated! Now the normal human experience of grief can be pathologized into the mental illness of depression—and treated accordingly, much to the benefit of the pharmaceutical industry. But what effect does this have on society?
As diagnostic inflation has ensnared more and more aspects of normal human emotional experience in the web of mental illness, many people are coming to think that any negative emotional experience is abnormal and a sign of illness. Anxiety and depression (which can both manifest in very serious forms) become labels to name any negative emotional experience. If someone feels a little sad today because they had a fight with a friend, they are depressed. If someone is feeling stressed about a number of upcoming deadlines, they have anxiety. The normal ups and downs of life become pathologized, leading to a sense of helplessness and a lack of emotional resilience among our young people.
Unknowingly embedded in this pathologization of everyday life, our young people toss around the labels anxiety and depression far too cavalierly and come to believe that every moment they are not happy, relaxed, and content is reason to believe they are ill. And their ability to rise above life's discontents is therefore seriously compromised.
Perhaps this is where a liberal arts education can be helpful, by foregrounding the emotional turmoil that has attended some of the great figures in history. Would Martin Luther have authored the ninety-five theses had he not suffered a major emotional breakdown? What role did Abraham Lincoln's well-documented depression play in making him America’s greatest president? How has emotional suffering played a role in many of the great literary, artistic, musical, and intellectual landmarks of history? Negative emotions are an inherent part of being human and may even inspire some of our greatest cultural achievements. They may be unpleasant, but they are not necessarily abnormal or signs of illness.
I have no doubt that my student was legitimately experiencing a stressful period in her life that did indeed make it difficult for her to concentrate. And she did need extra time for the assignment. But was she suffering from a mental illness or simply experiencing the stresses of normal life? She turned in her paper on the new due date and it was among the best in the class. She was clearly able to function at a high level despite her emotional difficulties. But will she be able to consistently call on this well of emotional resilience when she is socialized to believe that her stresses are a sign of a chronic mental illness that is "acting up"?
We must resist diagnostic inflation and begin to re-engage with the full panoply of our normal emotional reactions to the experiences of life, reactions that ultimately define what it means to be authentically human. After all, there is often greater insight and wisdom in misery than there is in contentment.