Lengthening shadow: will it be 'pull up your socks' or Prozac?

Do you suffer from a "shadow syndrome" mental disorder? Say what? Shadow syndromes are identified as mild mental disorders by two psychiatrists, Doctors John J. Ratey and Catherine Johnson, in their new book Shadow Syndromes (Pantheon, $25.95). These forms of psychic distress and maladaption are viewed as "subthreshold syndromes"; that is, they are not full-blown enough to appear as designated mental disorders in the current 886-page Diagnostic and Statistical Manual IV. The DSM is published by the American Psychiatric Association in an attempt to reach consistency in diagnosing mental disorders. It serves as the bible-Baedeker for all mental-health workers, and the insurance companies who fund them.

Naturally, a proposal to employ new diagnostic labels is going to initiate fights and conflicts within psychology and psychiatry, a field almost as contentious as ethics and religion. Moreover, such a move will further provoke those critics who regularly decry "the triumph of the therapeutic" and the dominance of "psychological man" in American culture. If so many individual behaviors become psychological disorders, what then becomes of free will and moral responsibility?

Indeed, those afflicted with these shadow syndromes are told by Ratey to stop blaming themselves and to seek treatment. Medications, such as Prozac, and various forms of psychotherapy are claimed to be effective. Many more troubled, and troublesome, individuals can now be helped to improve their lives rather than be seen as eccentrics or people with bad moral character. Yes, but does that remove the moral dimension entirely?

One of the most troubling examples of a shadow syndrome, for example, is the designation of a mild form of Attention Deficit/Hyperactivity Disorder. If you have never heard of ADD it is because the disorder has been so recently recognized and defined, especially as appearing in adults. From a moralist's point of view the diagnostic criteria for the full-blown syndrome given in the DSM include some rather suspect symptoms. Inattention, hyperactivity, and impulsivity have to be present for at least six months and to such a serious degree that they cause impairment. Included in the list of the symptoms are inattention to details, careless mistakes, losing things, forgetfulness, failure to follow through on instructions or to finish schoolwork, chores, or duties in the workplace, and (my favorite) "often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort."

The DSM also helpfully notes that these symptoms of "inadequate self-application to tasks" often cause interpersonal conflict. Family relationships are often characterized by resentment and antagonism because families can be mistakenly led "to believe that all the troublesome behavior is willful." Yes, those living intimately with these people cannot get over the tendency to hold them morally accountable. Furthermore, most of us, in the course of moral socialization, have learned to see that the suffering and negative consequences associated with avoiding sustained effort in life are our just deserts for refusing to reform bad behavior.

If this fully recognized and diagnosed syndrome in the DSM gives us pause, the milder shadow syndrome will seem more suspect. Such adult sufferers are described as not finishing reports or other projects because they get so easily distracted. So much for will power, discipline, and the painful mastery of the virtue of perseverance in the growing-up process. Prozac and psychotherapy to the rescue.

Other objections to creating new categories and labels of mild mental disorders also can be mounted, in and out of the mental-health establishment. Does scientific empirical research really support giving new "brand names" to conditions that haven't been thoroughly tested? A disorder doesn't get listed in the constantly revised DSM without a great deal of research data and hundreds of hours of debate by professionals. Should shadow syndromes be so hastily accepted?

Another worry is that new categories will contribute to the overmedicalization of society, something that afflicts us already. I once read a hilarious spoof by a shrewd internist purporting to be a case study of "the last well person in America." When it comes to the much more subtle and vague continuums of mental health, could we ever discover anyone to be normal? Surely fewer eccentrics could claim their rights to be tolerated as oddballs.

Worse still, won't new labels stigmatize whole new groups of people, with bad consequences? Would a politician be bumped from a vice-presidential candidacy if he admitted to suffering from a "shadow syndrome"? Well, we see the social and moral problems involved in the relentless march of progress toward mental health; we could end up a nation with universal diagnoses and rampant dependence on an array of psychoactive drugs to alleviate mental distress. Moral responsibility would be defined as the willingness to hie thee to a therapist.

Yet in the end, despite my objections, I admit to being deeply conflicted over these issues. It becomes increasingly difficult to define the boundaries between psychological disorders and full moral responsibility. Still, how can I refuse to approve efforts to alleviate the human suffering that is associated with maladaptive, inadequate (or immoral) behavior? I can't. Furthermore, I accept the mounting evidence that many physical ills actually mask psychological disorders. Much physical distress also can be relieved by psychological treatment. Healing may come in many guises, and should it ever be resisted?

Could not Christ's commandment to "judge not" apply to much of what now looks like voluntary acts of moral irresponsibility? If we are prohibited from declaring that any sinner will be damned to hell for sure, perhaps we should cultivate equal tentativeness in moral-psychological matters. Which is the better exercise of charity and prudence: diagnosis or moral blame? God only knows.