I read about a psychiatrist whose interests are in medical ethics and the improvement of medical care for youth coping with the complexities related to neurodivergence and significant mental health conditions. Additionally, she specializes in work with twice-exceptional (2e) individuals – those with exceptional talents and abilities who also navigate challenges related to disabilities or psychiatric illness.
Neurodivergence and 2e individuals are fairly new concepts for me. Back in the day, we used to call ADHD “minimal brain dysfunction.” High-fidelity wraparound services are referred to as quadraphonic sound systems. My, how has psychiatry progressed – or has it?
For the record, neurodivergence refers to the variation in the human brain regarding sociability, learning, attention, mood, and other mental functions. It’s a concept where neurological differences are recognized and respected as any other human variation. These differences can include those labeled with dyspraxia, dyslexia, ADHD, dyscalculia, autism, Tourette syndrome, and others. The term was coined in the autism community as a way to move away from pathologizing language used to describe these differences. Neurodivergent people often have unique strengths and perspectives, although they may also face specific challenges in neurotypical-dominated societies.
As physicians, we sometimes lose sight of our patients’ uniqueness. We tend to distance ourselves from their problems. We fail to see their originality and true character. We pretend we are different and better than our patients. But we are really no different, and each of us, in turn, eventually assumes the sick role, experiencing physicians from the other side and for who they are – ordinary citizens. It’s a humble reminder to embrace our differences – even celebrate them – rather than falsely elevate our status atop the proverbial pedestal.
Many creative people have been marginalized and tainted by psychiatric diagnoses. There has been a historical tendency to pathologize the behaviors and mental states of creative writers and artists, often linking them with psychiatric diagnoses. Many famous writers, such as Virginia Woolf, Ernest Hemingway, and Sylvia Plath, have had their creativity analyzed in the context of mental health conditions, including bipolar disorder and depression.
There’s a stereotype that links creativity with mental illness, suggesting that a person must suffer from psychological distress to produce great art or literature. This stigma can marginalize and isolate creative individuals, making it more difficult for them to seek help or to be understood by society.
While it’s true that some creative individuals may struggle with mental health issues, it’s important to note that creativity itself is not a symptom or result of mental illness. Many people with psychiatric diagnoses are not creative individuals, and many creative people do not have psychiatric diagnoses. The relationship between creativity and mental health is complex and multifaceted, and it’s essential to avoid generalizations and stereotypes, which is one of the main reasons the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR), has been heavily criticized and accused of setting psychiatric progress back decades.
The DSM is the tool used by clinicians to diagnose mental health disorders based on a set of criteria. The neurodivergent community and other groups marginalized by psychiatric diagnoses have objected to its usage on several grounds:
Medicalization of normal behavior. Critics argue that by continually adding new disorders, the DSM pathologizes normal behaviors or life stages. For example, grief after a loved one’s death could be diagnosed as a major depressive disorder, turning a normal human experience into a medical condition and treatment with antidepressants.
Overdiagnosis and overtreatment. With the expansion of diagnostic criteria, more people may receive diagnoses and subsequent treatments, including medication. This can lead to overdiagnosis and overtreatment, potentially exposing individuals to unnecessary side effects or risks.
Reliance on subjective criteria. Many diagnoses in the DSM are based on subjective experiences or behaviors, which can lead to variability between clinicians in diagnosing the same individual. This subjectivity can undermine the reliability and validity of diagnoses.
Influence of pharmaceutical industry. Critics suggest that the expansion of the DSM can be influenced by the pharmaceutical industry, which stands to profit from an increase in diagnoses and subsequent treatments.
Stigmatization. Labeling individuals with a mental disorder can lead to stigmatization and discrimination. The expansion of the DSM can potentially label more individuals as “disordered,” increasing the risk of shame and stigma.
Lack of biological markers. Unlike many physical health conditions, there are no clear biological markers or tests for most mental health disorders. This leads to criticisms of the DSM’s reliance on behavioral criteria for diagnosis.
These criticisms highlight the importance of using the DSM as one tool in a comprehensive approach to understanding and treating mental health, rather than as the sole basis for diagnosing or defining individuals by labeling them.
To its credit, the evolving field of mental health, as manifested in various iterations of the DSM, has become more sensitive and nuanced in its diagnostic approach, for example, by specifically recognizing the spectrum of neurodivergence without necessarily characterizing it as medically or psychologically abnormal. The DSM has made several changes from its previous versions to better recognize and respect the spectrum of neurodivergence without immediately pathologizing it.
Furthermore, the DSM has moved away from the multiaxial system, which is used to separate clinical disorders from personality or intellectual disorders. This change recognizes that these can co-occur and interact.
While such changes represent progress, it’s important to note that the DSM, like any diagnostic manual, is a tool with limitations. Its primary purpose is to provide a common language for clinicians to communicate about mental health conditions. It is not intended to define individuals or their potential. Every individual’s experience with neurodivergence is unique and should be understood in a holistic and respectful manner.
I know an instructor who is fond of telling her students: “You are all welcome here, and all of you are welcome.” This phrase is often used in therapeutic or supportive settings to create a sense of safety and acceptance. It communicates that every student is welcome, regardless of their background, experiences, emotions, or thoughts. Moreover, it also signifies that all aspects of a person – their joys, sorrows, fears, strengths, weaknesses, etc., are accepted and welcomed. This phrase is often used to foster a non-judgmental, inclusive, and empathetic environment.
Its implications extend far beyond the boundaries of the DSM.
Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine and Medicine on Fire: A Narrative Travelogue.
