In Praise of the Spectrum

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In one of my classes earlier this year, a student described how hard it had been for her to get treatment for attention deficit hyperactivity disorder (ADHD) when she was struggling in high school. Her father told her she wasn’t working hard enough. She begged to see a therapist but had to wait until she went to college to act on her own. With no hint of shame, she told the class: “Getting diagnosed with ADHD was one of the best days of my freshman year because someone actually saw that I wasn’t stupid or lazy, that I just needed treatment.”

Another student in the class, an advocate for neurodiversity, the movement that argues cognitive differences are a natural and positive part of human variation, wore a T-shirt that read “I hate normal people.”

Students and colleagues occasionally accuse me of being overly optimistic, but I can’t help interpreting such comments as a sign that millennials are successfully challenging the stigma and silence that have for so long shadowed mental illnesses. Despite the fact that the majority of people with a mental illness in the United States still receive no mental health treatment, mental illnesses are fast becoming a more accepted and visible part of life. In fact, many of the people we most admire—celebrities like Lady Gaga and swimmer Michael Phelps, for example—speak publicly about their emotional struggles.

Why millennials? And why now?

I can’t pretend to have all the answers, but I’m confident about two of them. First, because most psychiatric conditions have their onset in adolescence or early adulthood younger people’s experiences with mental illness will reflect changing attitudes in their community or among mental health care professionals. They are on the front lines facing any new diagnostic ideas.

Second, the new diagnostic idea they meet is the recognition among advocates and scientists that mental illnesses are spectrums rather than discrete disorders, and that we all lie somewhere on a continuum of suffering. There is, embedded in the idea of a spectrum, the notion that mental illnesses are an integral part of the human condition.

Pioneering researchers like Lorna Wing, Judith Gould, and others first introduced the idea of an autism spectrum more than four decades ago, and in the last decade neurodiversity advocates have pushed forward, reframing autism as a spectrum that can account for enormous variation among people with a range of strengths (such as skill in the arts, mathematics, and computer technology) and challenges in social communication, from the very mild to the very severe. Scientists demonstrated that mild symptoms of autism are common in the general population and that family members of a person with autism often exhibit autistic traits. Yet only that one person may actually have the diagnosis, either because they need some sort of treatment or because the diagnosis drives an intervention like special education.

With autism, as with many medical conditions—like hypertension and obesity—the boundary lines are drawn more by culture than by nature. Dividing human differences into distinct illnesses (or even genders) is like dividing up the color spectrum into distinct colors. While most of us can easily tell the difference between yellow and orange, we probably can’t agree on exactly where yellow ends and orange begins because there is no single point at which one becomes the other. Similarly, the border between health and sickness is the judgment call we make about whether a person’s symptoms are impairing their lives and warrant treatment.

Yet for decades, during the time the DSM-III (1980–94) and DSM-IV (1994–2013) were in use, researchers and clinicians tended to talk about mental illnesses in categorical terms—one either had or did not have a particular mental illness. In the wake of social movements that promote nonconformity—like neurodiversity and the transgender rights movement —the DSM-5 has now (2013–present) added a dimensional scoring component. The manual still uses names and categories to conceptualize groups of symptoms, to justify treatments and accommodations in work or school, and to prevent insurance fraud. But the dimensional model encourages clinicians to pay more attention to describing the severity and dynamics of a patient’s various symptoms over time than assessing whether a patient meets every criterion for a specific disorder.

What’s more, the DSM-5 now classifies all the major diagnoses as spectrum disorders (e.g., the schizophrenia spectrum, bipolar spectrum, and obsessive-compulsive spectrum), as happened with autism more than a decade ago. “Like most common human ills,” the DSM-5 states, “mental disorders are heterogeneous at many levels, ranging from genetic risk factors to symptoms.” As one leading epidemiologist put it, “there is no evidence for the existence of true discrete mental illnesses that account for the patterns among symptoms in dimensional assessments.”

These days, I sometimes hear someone describe their attitudes towards cleanliness as “a little OCD.” I don’t think they are saying they actually meet the DSM criteria for obsessive-compulsive disorder. Nor do I think they are minimizing how severe the condition can be. But by putting themselves on the spectrum, they are rejecting the illusion of “normality.” The spectrum, a hallmark achievement in the history of mental health, is an invitation to join the rest of the world on a continuum. It asks us to say, along with neurodiversity advocates, that both normality and abnormality are fictional lands no one actually inhabits.

Recently, I reeled off some prevalence estimates for my students: for example, 8-9 percent of American children have ADHD; 8–10 percent of children have an anxiety disorder; 2.5 percent of adults have bipolar disorder; 11 percent of 18- to 25-year-olds have major depression.

A student asked in jest, “Isn’t anyone normal anymore?”

I answered “No. Nobody’s normal. Normal is just a concept we use to stigmatize certain kinds of differences.”

The class nodded in agreement. They already knew.

The issue is that some people with some conditions that you personally would like to be cured or eliminated think “my condition can be explained using the neurodiversity model”, while other people who have conditions that you think are valid parts of human neurodiversity wish that they were neurotypical. There are some autistic people who even say that if an autism cure effectively killed them (by causing them to instantly become a very different person) then they would still want the cure.

As I see it, you have four broad options:

1) strict neurosupremacy
2) accepting some but not all neurodiversity in a categorical fashion - for example, “autism” might be accepted but “borderline personality disorder” might be cured.
3) the autonomy position - let individuals decide for themselves whether they are happy with their neurotype and whether they would like to try to change it
4) strict naturalism i.e. no changes to neurotype are ever allowed (this could be combined with #1 in theory)

I think #1 is probably the default position of most Western societies but #2 is also quite a popular proposition. #4 is largely theoretical.

The big flaw with #2 is that it is impossible to determine “good” and “bad” neurotypes objectively. Indeed, central to the neurodiversity paradigm is that different neurotypes may be more beneficial in a mixture even if they are less biologically “fit” individually. You mention psychopaths - frankly it’s probably easier to make the positive case for psychopaths than for autism. We already see, very commonly, NTs saying “it’s alright that some autistics support neurodiversity, but other autistics should be cured”. Usually they’ll say “low functioning” or give invasive details of symptoms they want eradicated. Never mind that there is widespread support for the neurodiversity movement from across the autistic spectrum. There will always be someone prepared to declare you too low functioning and call for you to be cured.

I have depression and anxiety. I think they are negative influences on my life and would like them cured. But, while my experiences are pretty widespread, I know they are not universal. There are people who say, look, I’d like help dealing with some of my symptoms, but I am glad that I have this mental illness. I have heard the journalist Micha Frazer-Carroll express those thoughts quite tentatively, to give one example. Clearly some people holding those views was what caused this thread to be started in the first place.

So I think we should recognise that neurodiversity isn’t limited to 200 psychiatric diagnoses, or five diagnoses that are sufficiently socially acceptable, but to 7.6bn unique human brains. Everyone should have a right to individually determine whether their brain deserves to be accepted or seek changes to it. In some cases we’ll be able to use categories to propose policy solutions for e.g. autistic brains, but these should always bear in mind that every autistic brain is different and catch-all solutions won’t always work.