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Stiamo trasformando le etichette psichiatriche in identità

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Un articolo del New Yorker dal titolo “Why we’re turning psychiaric labels into identites” affronta il complesso tema di come le certificazioni di disabilità possano trasformarsi in etichette identitarie che le persone non sono disposte a lasciare anche quando la riflessione su queste disabilità va avanti e le etichette vengono cambiate.

Tutto è cominciato con la creazione del Manuale diagnostico e statistico dei disturbi mentali:

Years of research and clinical observation have yielded catalogues of presumed mental dysfunction, culminating in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. First produced by the American Psychiatric Association seven decades ago, and currently in its fifth edition, the DSM organizes conditions into families such as “anxiety disorders,” “sexual dysfunctions,” and “personality disorders.” Each diagnosis is described by clear criteria and accompanied by a menu of information, including prevalence, risk factors, and comorbidities. Although clinicians and researchers have understood the DSM to be a work in progress, many had faith that the manual’s categories would come to approximate natural kinds, exhibiting, as the Columbia psychiatry professor Jerrold Maxmen put it in 1985, “specific genetic patterns, characteristic responses to drugs, and similar biological features.”

L’idea che i disturbi elencati nel manuale potessero essere ricondotti a cause fisiche chiare per adesso non solo non si è verificata, ma i dati che abbiamo fanno emergere un quadro sempre più contraddittorio e nebbioso:

The DSM as we know it appeared in 1980, with the publication of the DSM-III. Whereas the first two editions featured broad classifications and a psychoanalytic perspective, the DSM-III favored more precise diagnostic criteria and a more scientific approach. Proponents hoped that research in genetics and neuroscience would corroborate the DSM’s groupings. Almost half a century later, however, the emerging picture is of overlapping conditions, of categories that blur rather than stand apart. No disorder has been tied to a specific gene or set of genes. Nearly all genetic vulnerabilities implicated in mental illness have been associated with many conditions. A review of more than five hundred fMRI studies of people engaged in specific tasks found that, although brain imaging can detect indicators of mental illness, it fails to distinguish between schizophrenia, bipolar disorder, major depression, and other conditions. The DSM’s approach to categorization increasingly looks arbitrary and anachronistic.

Si è però scoperto qualcosa di inatteso: nonostante le etichette non sempre trovino fondamento scientifico e abbiano bisogno di essere aggiornate, una volta che le hai date alle persone, queste non sono disposte a vedersele tolte o cambiate perché hanno creato un legame con l’etichetta che le definisce e hanno lasciato che l’etichetta guidasse i loro comportamenti.

In “DSM: A History of Psychiatry’s Bible” (2021), the medical sociologist Allan V. Horwitz presents reasons for the DSM-5’s botched revolution, including infighting among members of the working groups and the sidelining of clinicians during the revision process. But there’s a larger difficulty: revamping the DSM requires destroying kinds of people. As the philosopher Ian Hacking observed, labelling people is very different from labelling quarks or microbes. Quarks and microbes are indifferent to their labels; by contrast, human classifications change how “individuals experience themselves—and may even lead people to evolve their feelings and behavior in part because they are so classified.” Hacking’s best-known example is multiple personality disorder. Between 1972 and 1986, the number of cases of patients with multiple personalities exploded from the double digits to an estimated six thousand. Whatever one’s thoughts about the reality of M.P.D., he observed, everyone could agree that, in 1955, “this was not a way to be a person.” No such diagnosis existed. By 1986, though, multiple personality disorder was not only a recognized psychiatric label; it was also sanctioned by academics, popular books, talk shows, and, most important, the experiences of people with multiple personalities. Hacking referred to this process, in which naming creates the thing named—and in which the meaning of names can be affected, in turn, by the name bearers—as “dynamic nominalism.”

Three new books—Paige Layle’s “But Everyone Feels This Way: How an Autism Diagnosis Saved My Life,” Patric Gagne’s “Sociopath: A Memoir,” and Alexander Kriss’s “Borderline: The Biography of a Personality Disorder”—illustrate how psychiatric classification shapes the people it describes. It models social identities. It offers scripts for how to behave and explanations for one’s interior life. By promising to tell people who they really are, diagnosis produces personal stakes in the diagnostic system, fortifying it against upheaval.

Just as personality tests (see, I’m an introvert!), astrological signs (I’m a Libra!), and generational monikers (I’m Gen Z!) are used to aid self-understanding, so are psychiatric diagnoses.

Per farsi una idea di come le persone si identifichino con le loro etichette e come reagiscano quando temono di vedersele tolte si può considerare la vicenda degli “asperger”:

The erasure of Asperger’s offers a glimpse into what a larger diagnostic revolution might herald. The term was coined in 1981 and first appeared in the DSM-IV, in 1994. Thriving communities soon developed around the label, including Aspies for Freedom, an online group that had close to fifty thousand members in 2013. Individuals with Asperger’s led the opposition to a unified autism diagnosis. Once they failed, and it became clear that the new manual would not only remove Asperger’s syndrome but also deprive many former Aspies of a place on the spectrum, the Autistic Self Advocacy Network successfully lobbied the DSM-5 neurodevelopmental-disorders working group to broaden the diagnostic criteria and allow people with previous Asperger’s diagnoses to be recognized as autistic. A community created by a label sought to keep that label alive and, barring that, to maintain their inclusion in the system writ large.

“But Everyone Feels This Way” is a heartfelt, vulnerable book about understanding and accepting autism in a world that constantly demands normalcy. At the same time, it hinges on the disorder being as it is presented in the DSM-5: both a spectrum and a natural kind, wildly various but biologically grounded. “I hope that, with knowledge and technology continuously improving in the science world, neurologists and other experts on neurodevelopment will eventually be the ones diagnosing ASD, not psychiatrists basing their diagnosis on arbitrary actions,” Layle writes. Yet the same research threatens to destabilize the spectrum and her place on it.

Internet poi ha creato delle comunità di auto-diagnosi che solidificano la propria identità tramite le etichette proposte dalle diagnosi e le utilizzano come scuse per il proprio comportamento:

Kriss recognizes how the process of labelling reifies categories, especially in the age of the Internet. Online communities such as the subreddit r/BPD crystallize psychiatric tags into identities to be socially accommodated and invite people to diagnose themselves. Such communities, Kriss fears, can “pervert” B.P.D. into a self-serving justification for misconduct. He cites the musician Abby Weems’s post about her relationship with the podcaster Dustin Marshall: “He made it so easy to rationalize his behavior, telling me ‘that’s just what happens when someone has BPD.’ His personality disorder made up so much of his identity that any abusive behavior fell under the umbrella of his condition.”

Come osservazione finale l’articolo nota che l’identificazione con le etichette può essere così forte che l’etichetta finisce per condizionare il comportamento di chi se ne appropria:

Yet there’s a broader issue here. People’s symptoms frequently evolve according to the labels they’ve been given. Following Layle’s visit to the psychiatrist, her mother observed, “You’ve been acting more and more autistic since we got the diagnosis.” Layle took the comment as a sign that her mom didn’t understand her—“I hate it when someone thinks I’m a liar,” she writes—but people everywhere encounter models of illness that they unconsciously embody. Some instances are subtle; others are dramatic and startling. In 2006, a student at a Mexican boarding school developed devastating leg pain and had trouble walking; soon hundreds of classmates were afflicted. A fifteenth-century German nun started biting her companions; eventually, the strange hysteria infected convents from Holland to Italy. Ian Hacking, the philosopher, argued that such a dynamic fuelled the epidemic of multiple personality disorder in the late twentieth century, and something similar seems to be playing out now with the growing portrayal of dissociative identity disorder, the current name for M.P.D., on social media. One of Kriss’s patients, a student who went by Haku, developed a multiplicity of selves after being introduced to the concept of dissociative identity disorder. “It’s not that I thought he was faking it,” Kriss recalls. “It seemed more that Haku wanted to have multiple personalities, even if that meant he had to force himself and others to believe in it.

Any new psychiatric taxonomy develops in the shadow of the old. It must contend with the echoes of the previous scheme, with people whose selves have been cast in the shape of their former classification. By failing to take these into account, models such as hitop risk re-creating the categories of their predecessors. Psychiatric diagnosis, wrapped in scientific authority and tinged with essentialist undertones, offers a potent script. As Layle wondered after she was told about her autism, “How did I know what was truly me, and what I had convinced myself I was?” ♦

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