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The Case for Cosmetic Psychiatry: Treatment Without Diagnosis

The Case for Cosmetic Psychiatry: Treatment Without Diagnosis

"Is that all there is?" may not be a question limited to recovering psychiatric patients. It is one that can be asked by any person, including those who do not meet diagnostic standards. Many psychiatrists tend to limit the application of their skills to those whose discomfort matches the phenomenological criteria of DSM-IV-TR.

It is the mission of this profession to render assistance to any who seek relief from emotional illness. This noble mission, however, does not currently apply to people who seek only subjective perfection. These are people who, while not experiencing a psychiatric disorder, wish to minimize the emotional discomforts of everyday life, reducing any minute impairment in their work life, love life or play life. It is therefore valid to ask: Can psychiatry transcend the concept of "objective cure" and include "subjective perfection" as a goal? Is there a logical reason why the concept of "treatment pills" cannot coexist with that of "lifestyle pills" on the psychiatric prescription pad? Cannot there be both "cosmetic" as well as "reconstructive" psychiatry? Does one need a disease in order to be treated?

By utilizing DSMs and other official disease catalogues, the psychiatric profession achieves mastery of its domain. It defines disease and then limits treatment to those who have disease: the patients. But the D-word can be applied and withdrawn at will. Homosexuality can be a disease or not, depending on the votes. Premenstrual syndrome can be accorded or denied disease status or relabeled "L2D2." Nicotine use can mutate from non-disease status to a dependency to an addiction. The scarlet D can or cannot be bestowed. But if it is not bestowed, one cannot be defined as "patient." Without the proper definition, no treatment is available.

All diagnostic categories, even the "V" codes (for other conditions that may be a focus of clinical attention) require a disease or problem state. The sick can be cured and made well; there is no room for the well who have no disease or problem, but merely wish to pursue their subjective definition of perfection. This definition may be particular to the individual, and it may even be peculiar. However, if it requires the psychiatrist to do no harm, then individuals should be able to expect professional guidance in pursuing their self-defined ideal state of being.

This pursuit, however, is blocked by a wasteland of introjected ideology and professional inertia. The operational medical protocol encompasses diagnosis, prognosis and treatment. As such, it may be a quantum jump to practice in the absence of diagnosis and prognosis and then proceed immediately to treatment. What HMO will authorize treatment for a wish that is neither Axis I disease nor a V code problem? Indeed, how does a psychiatrist justify prescriptions for people who have unfulfilled ambitions, not diseases? How does the psychiatrist fill in the "diagnosis" line on mail-in prescription forms? For the strictly disease-oriented psychiatrist, it may be difficult to prescribe a medication without a PDR-recognized indication or "minority school of thought" for support.

Well people seeking subjective perfection are discouraged by physicians wielding the persuasive powers of diagnostic definition--no diagnosis or label, no prescription, no pills. Acceptance of the label redefines the "well" as the "unwell."

By such transformative redefinition, the well are not seeking cosmetic change; rather, the sick are asking for cure. Now defined as "patients" who are ill, they can receive prescription medication. Well people are now diagnosed as "dependent," "addictive" or the all-encompassing "personality disorder not otherwise specified." Ideology is served. Choices can now be made on the basis of social coercion, not individual choice (Foot, 2002). Who, indeed, is to be master?

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