You Gotta Be Crazy

Data from the government-sponsored National Comorbidity Survey Replication, consisting of interviews with a sample of more than 9,000 people, indicate that most Americans suffer from a mental disorder at some point in their lives and that a quarter are diagnosable in a given year. Skeptics, including many psychiatrists, argue that such surveys overestimate the incidence of mental illness because they do not include the sort of in-depth examination that a careful practitioner would conduct before diagnosing someone. A 2002 study published in the Archives of General Psychiatry found that applying "clinical significance criteria" substantially reduced past-year prevalence estimates based on the National Comorbidity Survey. The estimated rates for anxiety disorders and mood disorders were reduced by about a third, while substance use disorders dropped by a quarter.

But given the broad sweep of the Diagnostic and Statistical Manual of Mental Disorders, it's hardly surprising that most of us arguably qualify for a psychiatric label. The question is whether that's an indication of how mentally sick we are or of how unscientific psychiatry is. If you set out to catalog every negative state of mind and pattern of behavior as a psychiatric disorder, you will ultimately prove that all of us are mentally ill at least some of the time.

"The problem," Johns Hopkins psychiatrist Paul McHugh tells The New York Times, "is that the diagnostic manual we are using in psychiatry is like a field guide, and it just keeps expanding and expanding….Pretty soon we'll have a syndrome for short, fat Irish guys with a Boston accent, and I'll be mentally ill."

In defense of the survey, the lead author says:

If I told you that 99 percent of Americans have had a physical illness, you wouldn't blink an eye. The fact is that there is a very wide range included here, with the equivalent of many psychiatric hangnails. We don't want to demonize those, but we don't want to trivialize them, either, because we know in many cases they lead to serious problems later on.

The thing is, we know what an actual hangnail looks like, and there's little room for dispute as to whether a patient has one. With "psychiatric hangnails," by contrast, the decision to call them illnesses, as opposed to psychological difficulties or problems in living or spiritual crises, seems utterly arbitrary.