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Looked at in this way, and as will become clearer in later chapters, mental disorders aren't therefore waiting to be discovered, like molecules or bacteria. They are much like man-made constellations
which are imposed upon the night sky
. Sometimes these map-makers draw patterns that make sense, but sometimes they do not, and sometimes they make mistakes so dramatic that it's hard to put things right again.

As I stood in Princeton that balmy evening, I knew that I now must explore what happens when mistakes are made. What happens when human traits are linked up into configurations that you and I would not recognize as psychiatric disease? And if the constellations increase in number, is there a danger they will begin to colonize so much of our emotional landscape that little remains which can be called
normal
? This was a question I now knew I had to pursue in my next set of interviews.

THE MEDICALIZATION OF MISERY

I
n late June 2011, I met Sarah Jones, a single mother of two and a care worker at a community center in West London. Sarah had a warm smile and a welcoming manner, and as she spoke about her family and work, her love for both shone through. But when the topic turned to her 7-year-old son, Dominic, she seemed suddenly overcome with anxiety.

“Dominic is a lovely boy, he really is, but last year he started getting agitated and aggressive. He was doing badly at school, being disruptive, and then he got into a fight. The school psychologist wanted Dominic to get a doctor's assessment, and I felt under real pressure to go. So after seeing Dominic for twenty-five minutes, the doctor said he was suffering from ADHD [Attention Deficit Hyperactivity Disorder] because he had all the classic symptoms: hyperactivity, impulsivity, and inattention. The doctor said medication would help. So Dominic is now on pills—and yes, he seems less distracted sometimes, but he also doesn't seem himself either. It feels like a part of his spirit has gone.” Sarah's distress was palpable. “I just don't know what to do.”

Month on month, year on year, increasing numbers of children like Dominic are being diagnosed with mental disorders like ADHD. In fact, diagnoses of ADHD have risen so sharply in the last ten years that 5.29 percent of the global child population is now thought to suffer from the condition (with prevalence rates in North America and Europe being pretty much equal at around 5 percent).
26
This vaulting rise in ADHD is consistent with a growth in other childhood psychiatric disorders. If we add up the prevalence rates for all childhood disorders, for example, it is estimated that between 14 percent and 15 percent of children now suffer from a diagnosable mental disorder in any given year.
27

But as high as these figures may be, they pale in comparison to those relating to the adult population. For example, the National Institute for Mental Health in the United States now claims that about 26.2 percent of all American adults suffer from at least one of the
DSM
disorders in a given year
28
while the Office for National Statistics on Psychiatric Morbidity in the UK reports a similar figure.
29
This amounts to saying that
at least
one in four people
is afflicted by a mental disorder in a given year each side of the Atlantic, a figure made more startling when in the 1950s it was more like one in a hundred, and at the beginning of the twentieth century a meager one in a thousand. So what can account for this massive surge in mental disorders? Why in just a few decades have we apparently all become so psychiatrically unwell?

There are at least three hypotheses the mental health community uses to try to account for the escalating rates. And as the book unravels, we will look at them in greater depth. But to give you just a quick snapshot, let me outline them briefly below.

The first goes like this: As the pressures of contemporary life have increased, so too have our levels of stress and strain, leading to an upsurge in poor mental health. While this explanation seems reasonable enough, as we will see later it is difficult to ascertain whether contemporary life is really so much more stressful than life many decades ago. Indeed, as many sociological studies have shown, social stress may have decreased rather than increased in recent years, therefore putting this hypothesis under strain.
30

The second hypothesis is also problematic: it says that mental disorders have increased because today's psychiatrists are better than those in the past at recognizing psychiatric disease. Perhaps advances in technology now allow clinicians to more readily spot and diagnose disorders that once slipped below their radar. While this hypothesis again has some obvious appeal, its weakness is that by and large diagnostic technology has not improved—there are still no objective tests that can confirm the validity of any psychiatric diagnosis, a fact supported by the continued low diagnostic reliability rates.

To be at our most generous, then, the first two hypotheses are, at best, plausible explanations that can partly account for the rise in disorder rates. But what if these hypotheses do not reveal the whole picture? What if they overlook a crucial yet not-so-obvious third possibility: that psychiatry, by progressively lowering the bar for what counts as mental disorder, has recast many natural responses to the problems of living as mental disorders requiring psychiatric treatment. In other words, has psychiatry, by redrawing the line between disorder and normality, actually created the illusion of a pandemic?

Let's now look at this third hypothesis in greater depth.

2

In March 2011, a group of scientists undertook a comprehensive study on nearly one million Canadian schoolchildren. What they did was look at the medical diagnoses all these children had received within the period of one year. These children were between the ages of six and twelve. The scientists were particularly interested in how many of them had been diagnosed with ADHD. Once the calculations were conducted and the results came in, the scientists were initially baffled by what they found: the precise month in which a child was born played a significant role in determining whether or not he or she would be diagnosed with ADHD.

As odd as this may sound, the figures published in the
Canadian Medical Association Journal
are plain to see. The line that charts the monthly diagnostic rates, rather than resembling a mountain range that peaks and dips from month to month, instead moves steadily and diagonally upward from the beginning of the year in January right up to the end of the year in December. To translate this into numerical terms, we find that 5.7 percent of all boys born in January were diagnosed, compared with 5.9 percent born in February, and 6.0 percent born in March. After that, the monthly rates rise incrementally until boys born at the end of the year are 30 percent more likely to be diagnosed than boys born at the start.

If this figure seems startling to you, then just consider the female diagnostic rates: Girls born at the year's end in December are 70 percent more likely to be diagnosed with ADHD than girls born in January. So what is going on here? Why are children born at the end of the year far more likely to be diagnosed with ADHD than children born at the beginning?

The clue to unraveling this puzzle has nothing to do with birth signs or weather patterns or cosmic shifts in the lunar calendar. It rather has to do with the simple fact that children in the same year at school can be almost a full year apart in actual age. This is because children with birthdays just before the cutoff date for entering school will be younger than classmates born at earlier times of the year. So in Canada, for example, children born at the beginning of the year (January) are eleven months older than classmates born at the end of the year (December). This means that January children have a full eleven months of developmental advantage over their December peers. And an eleven-month gap at that age represents an enormous difference in terms of mental and emotional maturity.

As I was keen to find out more about the implications of this study, I interviewed Dr. Richard Morrow, one if its lead researchers.

“Well, the most important thing we noticed,” Morrow said candidly, “was that the younger kids in the classroom were far more likely to be diagnosed with ADHD because their relative immaturity was being wrongly mistaken for symptoms of ADHD.”

The relative immaturity of the younger children was, in effect, being wrongly recast as psychiatric pathology. “And this clearly explained for us,” continued Morrow, “why the younger you are in your class the more likely you are to be diagnosed with this condition. And this is happening not just in Canada, because we found that wherever similar studies have been conducted [e.g., the United States and Sweden] they have reached the same results—the younger you are in your class, the more likely you'll get the diagnosis. It's a pretty wide phenomenon.”

The reason why Morrow's research is so important to us is because it provides a clear example of what is known as medicalization—namely, the process by which more and more of our human characteristics are seen as needing medical explanation and treatment. Now, while in the Canadian study it is clear that the effects of medicalization can be deleterious, this is obviously not the case in all instances. Indeed, medicalization, at best, has often been a force for good. For example, it was right to use medicine to cure biological conditions that were once unhelpfully understood as religious problems (to be healed only by prayer or church attendance).

And yet, as we have seen, there are forms of medicalization that are clearly unhelpful. These are the forms that invasively spread medical authority where it was never designed to go. For instance, “problems” such as low achievement, certain kinds of truancy, or underperformance have attracted medical diagnoses and intervention in our children, as have many normal reactions to the demands of adult life that are labeled as so-called “stress disorders” to be biologically explained and pharmacologically treated.

The issue of medicalization is crucial because it concerns where the very limits of medical intervention should be drawn. At what point does medicalization begin to undermine the health of a population? At what point does it begin to turn what should be a matter for spiritual, philosophical, or political understanding and action into an issue to be managed by medicine alone? This question has particular relevance for psychiatry. For psychiatry, as we will soon see, has been accused more often than any other medical specialism of incorrectly medicalizing our normal actions and responses. The question for us right now, then, is to what extent is this accusation true?

3

In an interview for a BBC documentary in 2007, the film's maker, Adam Curtis, posed this very question to Robert Spitzer. He asked Spitzer whether the
DSM
had committed any errors. More precisely, he asked whether when creating
DSM-III
his taskforce had adequately distinguished between human experiences that were disordered and human experiences that were not. In effect, had the taskforce, when creating its list of mental disorders, wrongly labeled many normal human feelings of sadness and anxiety as indicators of medical disorders that required treatment?

Spitzer, with noticeable regret, admitted that this had occurred. He then went on to explain why.

“What happened is that we made estimates of prevalence of mental disorders totally descriptively, without considering that many of these conditions might be normal reactions which are not really disorders. And that's the problem. Because we were not looking at the context in which those conditions developed.” In other words, Spitzer's
DSM
only described the symptoms of each disorder, but never asked whether or not these so-called symptoms could, in some circumstances, actually be normal human reactions to difficult life situations.

An incredulous Curtis therefore said to Spitzer: “So you have effectively medicalized ordinary human sadness, fear, ordinary experiences—you've medicalized them?”

“I think we have, to some extent,” responded Spitzer. “How serious a problem it is is not known. I don't know if it is 20 percent, 30 percent … I don't know. But that is a considerable amount if it is 20 percent or 30 percent.”
31

In this interview with Adam Curtis, Spitzer admitted that the
DSM-III
wrongly reclassified large parts of normal human experience—sadness, depression, grief, anxiety—as indicators of mental disorders that required medical treatment. This error occurred because his taskforce was only interested in the experiences that characterized the disorder. It was not interested in understanding the individual patient's life or
why
they suffered from these experiences. Because these contextual factors were overlooked, experiences of sadness, anxiety, or unhappiness were often listed as symptoms of underlying disorders, rather than seen as natural and normal human reactions to certain life conditions that needed to be changed.
32

You'll remember that I met Spitzer in early May in his house in leafy Princeton. As we sat eating lunch, I took the chance to ask him about the Curtis interview. Once I had recounted to him his exchange with Curtis, he slowly put down his spoon and turned his head in my direction. It was immediately clear to me he was unwilling to elaborate on what he had previously said.

It also seemed clear that he had shifted his position since that earlier interview with Curtis. While he still agreed that normal reactions were being recast as psychiatric illness, he now seemed keener to locate the cause of this problem elsewhere: not in how the
DSM
was constructed and written, as he had confessed to Curtis, but in how the manual is being used. As Spitzer explained:

“[In clinical practice] there is often too much emphasis placed by some on the diagnostic criteria of the
DSM
. [In simple terms, if a person has
this set of symptoms,
then they have
this disorder.
] This approach ignores other things that are important when making an assessment, such as the context in which the person became ill. So there has been a move toward an overemphasis on diagnostic criteria, and a neglect of assessing the social context in which the person is living.”

In other words, problems emerge when a psychiatrist simply tries to match the patient's experiences with one of the disorders in the book without investigating
why
the person is suffering as they are. After all, perhaps he is suffering because he has just lost his job, or someone dear to him, or because he's struggling with his identity, with poverty, with failure in love or work—who knows, perhaps his life just hadn't turned out as he'd hoped. There are countless understandable reasons why a person may suddenly start manifesting emotions or behaviors that can be easily misread as “symptoms” of “major depression” or “anxiety disorder”—reasons that may have nothing to do with the person being psychiatrically unwell.