Diagnostic Wannabes

Diagnostic Wannabes Jennifer Radden, PhD (bio) Saunders explores challenges for the clinician faced with self-styled sufferers from attention deficit hyperactivity disorder, post-traumatic stress disorder, bipolar disorder, autism spectrum disorder (ASD), and fibromyalgia. The diagnostic system was not meant to be used as “a scaffold for identity,” she points out. Yet wannabe patients now step into the clinic wielding self-proclaimed diagnoses as social identities. Saunders explains the context where such phenomena arise, and offers guidelines for clinicians addressing this new reality. To do so, she enlists Rashed’s innovative normative approach to the so-called boundary problem of assigning, and providing justification for, the contested line between normal and disordered. The boundary problem itself seems to rise to prominence during our current era of increasingly dimensional thinking, it is worth noting, with psychiatric diagnoses taken to refer to points on a continuum, rather than to discrete categorical disease entities. On the likely sources of these ‘diagnostic’ social identities, as well as reasons why certain diagnoses attach to them more commonly than others, Saunders points to social trends (including what she asserts to be a “post-stigma” cultural environment), the failure of efforts to identify neurobiological markers for psychiatric disorder, the ubiquity of social media, the algorithms themselves, and the hyperconnected existence of contemporary times. Such narratives also offer the comforts of a sense of belonging and explanations for perceived inadequacies, she rightly observes. Despite today’s virtual and other inducements, the problem introduced here is not an entirely new one. The first part of the seventeenth century in Europe saw an apparent “epidemic” of what was known as “melancholy,” a condition associated with the spleen, whose symptoms loosely resembled those of today’s depression and anxiety. Much of this suffering was undeniably real, but much was a fashionable, identity-conferring pose. “Every distemper of the body now is complicated with spleen,” the poet John Donne ironically observes in a letter dated 1622, “and when we were young men we scarce ever heard of the spleen. In our declinations now, every accident is accompanied with heavy clouds of melancholy”1 (Gosse, 2019). By then, the Melancholic Man (or homo melancholicus), with his surfeit of spleen, was an unmistakable character type—or social identity, as we would now say. Recognized and saluted in centuries-long literary and illustrative traditions, the type was an anchoring element of the humoral medicine which, despite the gradual emergence of more empirical science, had endured since Galenic times. Melancholy’s closest descendants, affective depressive and anxiety disorders, are today less evident among the troubling identities Saunders discusses—somewhat preempted, she points out, by more cognitively-based diagnoses such as ASD. [End Page 279] This is itself an ironic reminder of the vagaries of cultural attitudes, cautioning us to remember the broader context where these particular social identities are selected for emulation and adoption. The lure of the melancholy man’s2 social identity is well understood: already normalized, within the humoral system in which excess black bile afflicted roughly one in four people, it had been valorized for centuries—arguably by Aristotelian writing (in the dubious ‘Problems’), during the Renaissance by Ficino, and Shakespeare—even by Freud in his 1916 ‘Mourning and Melancholia.’ Through most of Western history, the positive attributes and benefits of the dark moods of melancholy have needed no further explaining or justifying. They glow with glamorous associations. Applying Rashed’s conditions for appropriately acknowledging and recognizing the fit of a person’s chosen social identity, Saunders‘ guidance for clinicians clarifies boundary matters. And it illustrates how to understand, regulate and communicate the appropriate norms in ways that can dissuade those whose personal growth and mental health are not served by claiming such identities. With at least some of the popular social identities Saunders describes, I think we can helpfully continue the comparison with the homo melancholicus. For the ‘neurodiversity’ rhetoric of our own times contains forces promoting both the normalization and the valorization of syndromes such as ASD. Pointing to analogies with differences of gender, ethnicity and culture, neurodiversity theorizing argues for a respect for, and appreciation of, difference. Mental or cognitive variations are equally natural and valuable, it is...