Monday, 22 February 2010

Why There Should Not Be An Adjustment Disorder

Reading Petra Boynton's blog, I see that the APA are taking comments about the forthcoming fifth edition of its Diagnostic and Statistical Manual, or DSM-V to the masses. In psychiatry this weighty tome has roughly the status that Halsbury's Laws of England does in the legal profession. Most important, if your particular screw-up doesn't fall into a DSM-IV (the current edition), your insurance company is not going to pay out for your treatment.

There's a thing called Adjustment Disorder. You have this if you become overly depressed, anxious or start behaving oddly within three months of a stressful or traumatic event, carry on doing so for at most six months after the event stops, and for that time have difficulty coping with work and life. If the event goes on and on (the boss is a bitch), the condition is chronic. If you go on being depressed, anxious or behaving oddly for six months after the boss moves on (or whatever) then you have something more serious. This looks okay, but...

You can hear the bullies lining up now, can't you? Your employer sacks you with no money - hey, get drunk on the day, curse them, let it go and move on. If you fall into a depression, that's you having an adjustment disorder and has nothing to do with them. They aren't responsible. Or your wife cashes you in, taking the house, kids, half the pension and maintenance. Adjust little buddy, no moping for you. It happened, move on and get on with your life. If you can't, it's not her fault, it's yours, because you have an adjustment disorder. It's all about what counts as over-reaction: who decides that? For the people who hand out the harm, that would be any sign of depression or reduced functioning at all; for the poor bloody victims, that would be all the blues they can feel. Your co-dependant friends would indulge you and your colleagues at work would get irritated if you came in the next day still moping.

Now compare this with the symptoms for a major depressive episode. To have one of these, you need at least five of the following nine symptoms, which must manifest for most of the day: 1) feeling sad, blue or depressed; 2) a loss of interest and pleasure in things you used to do; 3) significant changes in weight and appetite; 4) significant problems sleeping; 5) agitated or lethargic body movements; 6) feeling fatigue at least once a day; 7) low self-worth and inappropriate guilt; 8) persistent difficulty concentrating; 9) thoughts of death or suicide. The symptoms must persist for a two-week period and must include one or other of the first two. But here's the catch, which most casual readers of DSM (if there could be such a thing) miss: if you're hauling your ass out of bed, making it to work, paying the bills, baby-sit your brother's kids, keep the larder and the fridge full and even making it to the gym a couple of times a week, you don't qualify for being depressed. You qualify as feeling like crap and needing a change of life, but not as depressed. Because you're functioning, and if you're functioning, a psychiatrist can't diagnose you as crazy.

Notice that all these symptoms are as "objective" and "observable" as anything about human behaviour and psychiatry ever will be. Weight is objective, so is the time you wake up or the number of hours before you fall asleep; you get to report if you're feeling sad and anyone can see if you don't get as excited by football as you used to, can't concentrate or are dragging your sorry ass around the place instead of being spritely. No-one can impose their ideas of what's "normal" on you, though they can take a swig of denial and say that it's not as bad as you're making out. Imposing their denial is not imposing their values.

Many people criticise the DSM for what they see as the creeping medicalisation of normal behaviour. They have in mind the famous definition of ADHD as "behaviour that irritates primary school teachers". But that's the clue: it's the teachers, social workers, GP's and parents who medicalise the actual boisterous boy, not the DSM-trained psychiatrist, who is most likely to say "he's a boy, and you want him to behave like a girl?". There's a context to the DSM - it's for psychiatrists, not "councillors" or "therapists". On a daily basis psychiatrists see people who are severely fucked-up, people that we never see. They get the context and know what the words mean, we don't.

The real criticism isn't about medicalisation, it's about the use of social norms in psychiatry. It's that use of "overly" in the definition of Adjustment Disorder. It's maybe in the whole idea that we should "adjust" to the slings and arrows of outrageous misfortune at some rate that optimises our social and economic effectiveness while maintaining a facade of feeling humanity. I once read an account of children's attachment to their mothers. It was based round how the kids reacted when Mommy left them at the nursery. "Appropriate adjustment" was when the kid cried for a little - just enough to show it was missing mommy but not enough to be a nuisance to the teacher - and then went to play with the other kids. Too much crying was unhealthy, running straight off without missing mommy was unfeeling. That isn't psychology, it's manners at best and competitive parenting at worst: look at my appropriately-adjused child.

Being screwed-up is one thing, but not fitting in with the straights and normals is another. No-one is under an obligation to do that.

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