Pathologizing Discontent

“Humankind cannot bear very much reality”

Despite an overabundance of comforts and pleasures, we remain spiritually bereft. As our species climbed up from subsistence living¹, we decided spirituality was for our primitive ancestors who didn’t know any better. With the rise of the scientific method and rationalism, many came to view themselves as enlightened, having outgrown what they considered outdated modes of belief.

In exalting empirical evidence as the sole measure of truth, psychiatry was seen as the modern remedy for lingering mental woes. Yet with all the information at our fingertips and people seeking more care than ever before, what do we have to show for it?

Instead of mental illnesses declining, we find at best they are unchanged to rising, depending on the disorder in question. In research, this is called a treatment paradox prevalence (TPP).

Looking at depression specifically,

“The increased availability of effective treatments should shorten depressive episodes, reduce relapses, and curtail recurrences. Combined, these treatment advances unequivocally should result in lower point-prevalence estimates of depression. Have these reductions occurred? The empirical answer clearly is NO. Recent meta-analyses of epidemiological surveys in the general population of Western countries since 1980 do not report decreasing prevalence rates of depression. In fact, there may have been a slight increase as two out of three meta-analyses published since 1978 found a small upward temporal trend, while the third meta-analysis reported an unchanged prevalence.”

One theory behind the intractability of depression is our modern lifestyle:

the modern man would likely be much more resilient to the toils of living if he were physically fit, well-rested, free of chronic disease and financial stress, surrounded by close family and friends, and felt pride in his meaningful work. The temporal, cultural, and mechanistic evidence presented here prompt consideration for depression as a disease of modernity

And yet, modern life offers material advantages that would have been inconceivable a few centuries ago. Pre-industrial people lived hand to mouth. Today, we live in a caloric surplus. In the 1700s and 1800s, one white child in four or five wouldn’t survive to adulthood. While childhood death remains tragic, it is now rare in developed countries.

Stress is not new. To claim that the average person today experiences worse stress than someone hundreds or thousands of years ago is unconvincing. There’s a massive difference between stressing out how to respond to an email and wondering if your child will live through the night.

Thus, our perception of stressors has come unmoored. By elevating discontent² - an ordinary life experience - to an anathema, we are adopting the mistaken viewpoint life can be free from unpleasantness and fall into the rut of medicalizing everything.

It’s only a short hop from modern societal discontent to reducing someone to a victim of circumstances. A pervasive sense of victimhood has taken root.³ It’s as if feeling discontented is un-American.

Discontented individuals often expect others to accommodate their issues without changing their own behavior. As Jesus said, “Why do you look at the speck of sawdust in your brother’s eye and pay no attention to the plank in your own eye?”

In an insightful analysis, Christopher Lasch details the downside of psychiatry:

“Therapeutic modes of thought and practice exempt their object, the patient, from critical judgment and relieve him of moral responsibility. Sickness by definition represents an invasion of the patient by forces outside his conscious control, and the patient’s realistic recognition of the limits of his own responsibility—his acceptance of his diseased and helpless condition—constitutes the first step toward recovery (or permanent invalidism, as the case may be)…

Therapy labels as sickness what might otherwise be judged as weak or willful actions; it thus equips the patient to fight (or resign himself to) the disease, instead of irrationally finding fault with himself. Inappropriately extended beyond the consulting room, however, therapeutic morality encourages a permanent suspension of the moral sense….As therapeutic points of view and practice gain general acceptance, more and more people find themselves disqualified, in effect, from the performance of adult responsibilities...”

The plateau of discontent is formed by negative emotions. They are no longer seen as natural, but as inherently pathological. As a result, responsibility is abdicated. When people feel their behavior is wholly determined by genes and environment, personal agency erodes and victimhood takes root.

Conflating sadness with depression

Psychiatry can be too quick to label sadness as pathological. In a society that sanitizes discomfort, it’s easy to forget that pain often motivates change.

The book “The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder”, argues the explosion of major depressive disorder diagnoses “is largely a product of conflating the two conceptually distinct categories of normal sadness and depressive disorder and thus classifying many instances of normal sadness as mental disorders”.

Behind this lies a flawed diagnostic system. The DSM (Diagnostic and Statistical Manual of Mental Disorders) is the authoritative guide to diagnosing mental disorders. It arose from criticisms in the 1960s and 1970s that the same person would not be uniformly diagnosed across different psychiatrists because there was no litmus test.

In the creation of the DSM, doctors wanted to elevate psychiatry to the empirical levels of the other sciences. Further, there is the general human instinct to consider something solvable once it has been labelled. However, a label merely gives an idea structure.

However, the pursuit of reliability - diagnosis based on clear cut criteria - came at the expense of validity. This means the DSM opts for a trade-off of over-diagnosis versus under-diagnosis.⁴

Consider the severest form of depression: MDD (Major Depressive Disorder). Between 1991 and 2002, the one-year occurrence of MDD rose from 3.33% to 7.05% based on a community study of American adults. Another research paper on the same cohort found MDD prevalence rose from 6.8% in 2005 to 7.1% in 2015.

One diagnostic marker is bereavement lasting longer than two months. This is a stunningly short period to process profound loss, inadvertently capturing a broad swath of people who may meet this criteria (and others), but are not truly suffering from MDD.

Further, the symptom criteria MDD applies to a two-week period.⁵ You would meet the technical criteria for MDD with only half a month of depressed mood, diminished interest in activities, weight gain or loss or appetite changes, changes to sleep pattern, and fatigue.

This diagnostic test fails to consider the aforementioned activities are not discrete variables - that is, if you have a depressed mood, naturally you won’t enjoy activities and will encounter appetite and sleep changes. They are irreducibly linked together.

Normal sadness from typical life events like a breakup, job loss, moving, or discovering a loved one has a life-threatening illness can easily extend beyond two weeks. For example, five weeks after the 9/11 terror attacks, twenty percent of New York City residents reported enough symptoms to be diagnosed with MDD.

Similarly, the COVID-19 pandemic caused a surge in people meeting major depression criteria. The worldwide prevalence rate increased 28% during 2020.⁶

Contextually, feelings associated with MDD make complete sense following 9/11 and during the pandemic. The question is, to what extent of these is true clinical depression, as “it is the absence of an appropriate context for symptoms that indicates a disorder”. We live and move and have our being in a contextual milieu.

This is not to bash the DSM wanting a uniform set of criteria. Nor am I suggesting clinical depression does not exist. Rather, the argument is that not all emotional pain signals a mental illness.

Life is often grueling, and discomfort is a part of it. These experiences can catalyze growth. Without negative emotions, we might never change at all. We must distinguish between normal sorrow and true, pathological dysfunction. It is a good thing to relieve suffering, but not at the cost of mislabeling life itself as a disorder.

Indeed, some of my most profound personal growth occurred in the darkest of nights. Although I become a better person, make no mistake, I was often kicking and screaming along the way.

Once the corner is turned, I am thankful for the growth, not the experience. We can hold these opposite emotions - gratitude for improvement while never wanting to go through the same thing again.

A secondary order effect from elevating negative emotions to a disease is the prevalence inflation hypothesis. This refers to the theory

“that awareness efforts are leading some individuals to interpret and report milder forms of distress as mental health problems. We propose that this then leads some individuals to experience a genuine increase in symptoms, because labelling distress as a mental health problem can affect an individual's self-concept and behaviour in a way that is ultimately self-fulfilling.”

The elevation of discontent into something pathological can lead to actual mental disorders driven by one’s self-fulfilling prophecy. It’s little surprise being inundated with the viewpoint that normal life experiences shouldn’t be part of the human experience inevitably leads to heightened distress.

Arguably we suffer twice from deeming discomfort to be abnormal: from the pain itself and from the belief that we should not be feeling it.⁷

Conclusion

Pathologizing normal emotions is dangerous because it threatens to remove a sense of responsibility for one’s actions. It holds out the lie that a good life is devoid of discomfort.

The first step in addressing any problem is identification. My argument herein is we have medicalized/pathologized feelings, resulting in over-identifying with normal, though uncomfortable life experiences. As such discontent, a normal reaction to parts of the human experience, becomes mistaken for dysfunctional mental disorders. The end result of negative emotion sanitation is a pseudo-reality that costs us nothing less than our souls.

Instead of medicalizing discomfort, of seeking to avoid it while at the same time obsessing over it, this negative feeling must be embraced. Life’s meaning and purposes are forged in the discomfort and sadness. To paraphrase Viktor Frankl, we must have a ‘why’ so we can bear with any ‘hows’.

Empirically, recent research backs up the proposition that embracing discomfort is beneficial. On a neurological basis, one can learn to love the hard stuff.

By attaching dopamine to the effort process, the brain reward system is activated during the journey rather than being attached to the destination. Dopamine is the neurotransmitter linked with motivation - it draws us towards things.

Endurance athletes know the love/hate relationship with embracing the suck, of entering the pain cave all too well. A glaring weakness of mine historically has been endurance workouts - I hate the discomfort.

A recent breakthrough occurred when I told myself on my cardio days that it was going to suck for the first twenty plus minutes. By acknowledging that it’s supposed to be hard and leaning into the suck, I feel stronger and less mentally fatigued throughout.

The same is true in my day to day life. Cognitively, I know life is hard. Yet implicitly, I didn’t believe it should be this hard. Now when I find myself complaining, I try to reset: “Life is hard and hard things are worth doing.” Accepting the central premise of life’s difficulties and turning it into a positive has increased my resilience and ability to remain calm.

This is an example of having a growth mindset. In other words, it is the belief that one can grow from embracing challenges and persisting in the face of setbacks. It’s opposite, a fixed mindset, subscribes to the view that qualities like intelligence, abilities, and life itself are fixed.

By viewing typical, albeit unpleasant life experiences as opportunities, and by being willing to “fail”, paradoxically you succeed.

“Growth demands a temporary surrender of security.” - Gale Sheehan

If discomfort cannot be welcomed with open arms, at least allow it a place at the table. It will be there anyways, and it is much better to accept what is rather than operate from a place of denial. Emotional maturity will remain elusive until this is fully grasped.

Author’s note: with respect to medication itself, this post remains silent on the issue, as I believe the responsibility lies with each person as to its appropriateness.

1. To be more accurate, around 25% of the population still engages in subsistence farming.

2. Author’s note: Discontent and discomfort are used as umbrella terms for negative emotions like sadness and anxiety.

3. The other side of the victimhood coin is entitlement, but that is deserving of its own post. My paradoxical theory is we expect too little of people.

4. Over-diagnosis is a Type I error or a false positive - meaning people will meet clinical depression symptoms even when they do not have depression pathology. Under-diagnosis is a false negative, or Type II Error, where someone does not meet depression criteria but does in fact have clinical depression.

5. Even though the symptom criteria occurs over two weeks, diagnosis tests nevertheless represent a point in time (the scientific term is point prevalence) rather than a flow. Recency bias can result in conflation of acute with chronic symptoms.

6. In the interest of transparency, baseline prevalence both before and after COVID-19 in this survey was notably below other papers highlighted. For our purposes, I was concerned more with the trend change rather than overall occurrence.

7. And when professionals validate this viewpoint, it deepens our illusion. At least in the U.S., psychiatric doctors have implicit pressure to do something when you visit them. Whether this comes down to receiving repeat business, getting more insurance money, a self-justification strategy of their own, or an attempt to assuage the patient, I’m not entirely sure. What I do know is I have never walked out of a doctor’s office sans a prescription after going in with a complaint.