Contesting normal: The DSM-5 and psychiatric subjectivation

In this paper, we analyze the debates surrounding the fifth edition of the Diagnostic and Statistical Manual (DSM-5), psychiatry’s manual of mental disorders. One critical component of the recent DSM-5 debates focuses on how expanding definitions of illness reconfigure the underlying category of ‘normality.’ The literature on biomedicalization and neoliberalism suggests that we have moved past the discrete categories of abnormal/normal into an era in which we all must strive for scales of normality, only achievable via scientific optimization – a shift from normalization to normation. However, the DSM-5 debates suggest that this argument may be too totalizing. Many commentators on the DSM-5 revisions pine for an idealized era when the normal and abnormal were ontologically differentiated in dichotomous terms. We show how this desire to salvage normality from the ambiguity of the norm and the expansion of psychiatry’s domain over human conduct constitutes a critique of the neoliberalization of mental health and the biomedicalization of everyday life, which nonetheless essentializes ‘human nature.’ We excavate these figurations of the normal to highlight the ways in which psychiatry both relies upon and troubles the binary between normal and abnormality, and between optimization and essentialization.


Introduction
Released in 2013, psychiatrist Allen Frances's book Saving Normal garnered significant media attention amidst growing public concern over the role of psychiatric diagnosis in contemporary life. Citing his own experience as the leader of the fourth Diagnostic and Statistical Manual (DSM-IV) revisions, Frances introduced his book as a response to the ''civil war'' at the heart of American psychiatry. Psychiatrists like him, Frances contends, are in a ''…losing battle to protect normality from medicalization'' (xii). Frances frames the book as a call to arms against the American Psychiatric Association (APA), the creator and publisher of the DSM. Frances incites the APA to reign in the runaway DSM-5, 1 to limit the number of disorders listed in the book, and to discourage practitioners from handing out so many diagnoses. Frances frames this problem as one of ''shrinking normality.' ' We have what Frances calls ''false epidemics'' of childhood bipolar disorder, attention deficit disorder, and autism. We do not have, Frances argues, a true conceptualization of ''health'' in psychiatry, because normality is neither defined nor protected.
Indeed, much of the public debate surrounding the release of DSM-5 centers on this question of human normality: where its boundaries should be drawn and by whom. Unlike psychiatric debates of previous decades, which zeroed in on supposed deviant figures such as masochistic women and gay people (Kutchins and Kirk, 1997), the DSM-5 debates problematize normal itself, suggesting a new era of psychiatric critique and upheaval. In this paper, we consider how discourses on disorder construct the underlying category of 'normality,' and we question how that category comes to matter when diagnostic authority falters.
Between February 2010, when the APA posted its draft of the new DSM-5 criteria online, and May 2013, when the APA released the manual, psychiatric knowledge and diagnostic science became the focus of a series of public debates. Some of these debates question the professional and epistemological foundations of psychiatry itself, with leaders in the field sparring over the biological roots of psychiatric disorders, disagreeing about how the future of psychiatric research should unfold, and fighting for ownership of the terms of mental disorder. Another set of debates, however, touch on a vast and nebulous public anxiety about the role of diagnosis and psychiatric culture in shaping contemporary personhood. It is this second debate that we highlight in this paper. Drawing on data from newspaper, blogs, and popular books about the DSM-5, we show how public scientific debates can shed light on the lumpy nature of biopolitical transformations, which are often ignored by theorists in favor of totalizing claims.
Social scientists frequently take up the resisters and promoters of medicalization as objects of analysis. As Martyn Pickersgill notes about the DSM-5 debates, ''In some senses, there is nothing especially novel about the debates…critics have long attacked the validity and reliability of the DSM, and indeed the wider kinds of medicalization it is often deemed to promote'' (Pickersgill, 2013, p. 2). And certainly, processes of medicalization frequently compel public and expert commentary, both as critique and endorsement. And yet, the fervor of the DSM-5 debates is quite unusual in post-1980s psychiatry, especially given the ubiquitous nature of psycho-pharmaceutical interventions in the U.S. healthcare system (Horwitz and Wakefield, 2007). Indeed, Owen Whooley characterizes the DSM-5 controversy as an important challenge to psychiatric authority, which has created a cleaved scientific field (2014). Thus, along with Whooley (2014) and others (Callard, 2014;Pickersgill, 2013), we contend that the DSM-5 debates present a unique moment for social scientific inquiry, one in which a scientific field falls under intense public scrutiny and experiences professional infighting, both of which are recorded and stoked by spirited news coverage, lay commentary, and incendiary public statements.
In our analysis, we highlight facets of the DSM-5 debates that critique the neoliberalization and biomedicalization of mental life. We show that even as these critiques abound and participants seek to slough off psychiatric labels, other stakeholders hold steady to their diagnostic categories, agitating to remain under psychiatric purview. We argue that the empty figure of normality is central to the inconsistent operations of biomedicalization, such that it compels both critique/regression and celebration/optimization. Many have argued that biomedicalization has introduced a compulsion to self-optimize, yet the DSM-5 debates reveal gaps in such mandates. Thus, we intervene in the literature on biomedicalization and neoliberalism by suggesting that the cultural transformation toward self-optimization via health and wellness is not totalizing, but uneven. There are times when the call to work on our health via technoscientific intervention fails, and when it does, there is often a countercall to return back to some idealized version of normality, lurking beneath overmedicalization. The shadow figure of normality in biomedical constructions is central to understanding the lumpiness of biomedical expansion and lay reactions to neoliberal medicine.
In order to show how psychiatry's shadow figure of normality undergirds biomedicalization processes, we highlight the discrepant ways in which the DSM-5's critics engage discourses of disorder and wellness. First, we show how the DSM-5 debates compel a cultural discourse of anxiety around diagnosis, psychiatric labeling, and pharmaceuticalization. We then parse the various ways in which these critics construct normality -either as an innate human potential or a pre-modern self unencumbered by scientific knowledge. Through these constructions of normality, we show how the DSM-5's critics end up arguing for a reinstated normal/abnormal binary in their critiques of psychiatry's neoliberalization and expansion. Thus, while scholars of neoliberalism and biomedicalization suggest that we have moved completely away from binaristic notions of normality and wellness (toward a normal curve), we argue that binaries still operate importantly in psychiatric discourse, even those that circulate as 'progressive' or humanistic. Finally, we use autism and depression as opposite examples of biomedicalizing shifts: in the case of autism, normality is constructed as a future achievement predicated on behavioral intervention; in the case of depression, normality is imagined as an innate human capacity necessary for healthy selfhood and progress. These conflicting biomedicalization processes suggest that the mandate to optimize the self via technoscience is not complete or final, and that it depends on how the implicit figure of normality is wrought.

Literature Review
In his lectures at the Collège de France from 1974 to 1975, Foucault suggests a prominent shift during the 19th century in our understanding and treatment of the abnormal (2003). The abnormal is constituted historically (from the 18th century until the end of the 19th century) on the basis of three figures: the human monster, the individual to be corrected, and the onanist (masturbator). These figures begin as distinct formations under the disciplinary control of different institutions: politico-judicial powers, the family, and the church. But they merge with the expansion of psychiatry and the invention of the instinct, which reconfigures abnormality as a potential that resides in us all. As a result, conduct itself becomes the domain of psychiatry. Deviations from the norm along the axis of voluntary versus involuntary conduct become the dividing line between mental health and illness (pp. 159-160). '' [T]here is nothing in human conduct that cannot, in one way or another, be questioned by psychiatry … Any kind of disorder, indiscipline, agitation, disobedience, recalcitrance, lack of affection, and so forth can now be psychiatrized' ' (pp. 160-161). Mental illness is thus fully somatized (p. 162).
This transformation mirrors another shift noted by prominent Foucauldians from a regime of discipline to one of control, when probability assessments and risk management supplant surveillance and docility as regulatory apparatuses. We are no longer dealing with disciplinary tactics of individualization, but rather, with the construction of ''dividuals''not subjects with innate qualities but rather capacities and potentialities (Deleuze, 1997, p. 180;Rose, 1999, p. 234). This constitutes a shift from normalization (where certain individuals are conceived of as ontologically abnormal, based on a binary model of differentiation) to normation (where difference is conceived of as a normal curve and everyone has the potential for abnormality) (see also : Foucault, 1963). However, as in all of Foucault's work, these shifts are never total. There are moments when disciplinary forms of binary categorization emerge in the interstices of the new control society, which is precisely what we see in the debates surrounding the DSM-5. Rose (2007) argues that, in 21st century Western culture, discourses of 'normal' health have moved into the realm of 'choice' and 'enhancement': Previously, one might suggest, the role of medicine was not to transform human capacities but to restore a lost normativity. The body had its natural norms, illness was a loss of those norms, and medical interventions sought to restore those norms or to mimic them in some way … But these norms no longer seem so normalizing, these normativities appear in principle open to conscious manipulation … Some of the normativities once considered to be inscribed in the laws of organic life itself have already moved, at least in the wealthy West, into the field of choice, and are laden with all the demands that choice imposes. (p. 81) In other words, the rise of biomedicine and the life sciences -both as scientific fields and as discourses of the self -have created conditions in which we no longer try to regain some 'normality' underneath symptoms; rather, we reach for optimized selves through biomedical interventions. The norms that undergird our bodies are ''open to manipulation,'' to expert management and enhancement. Indeed, Rose contends that we are no longer concerned with health and illness as stable concepts or norms, but with ''the optimization of life itself'' (p. 82). Biomedicine may seek to restore some sort of normativity, but it is not the same normativity that existed before -it is a new form of life: enhanced, desired, improved. Enhancement, Rose argues, becomes the new authenticity, the 'new normal. ' Rose (and others who have theorized this shift) suggests that this is a unilinear and uncontested process, an essential if unfortunate symptom of late modernity and the encroachment of biomedicine over ''life itself.'' Similarly, Clarke et al suggest that biomedicalization entails a reconstitution of medicine by technoscience (under late modernity), which extends medical jurisdiction over health such that the management of illness becomes an individual moral responsibility to be fulfilled through self-surveillance (2003,2010). Conrad defines medicalization as the increasing domain expansion of medical labels and expertise over more and more aspects of everyday life (2007). Clarke et al suggest that medicalization is co-constitutive of modernity and focuses on the expansion of disease categorization, whereas biomedicalization is co-constitutive of post-modernity and focuses our attention on the broader realm of health, turns our gaze inward toward our internal state of being, and is accompanied by a decentralization of medical authority and expertise (Clarke et al, 2003). Risk and surveillance are no longer contained within certain institutions (the hospital) or sets of relations (doctor-patient), but are extended over all facets of life. Medical interventions come to exert control over bodies even without the presence of illness, as the standards of public health infuse language about the self, body, and identity (Clarke et al, 2003(Clarke et al, , 2010. Thus, diagnoses are not simply pronouncements of biomedical knowledge or technocratic tools, but they operate as diffuse cultural categories that confer meaning about identity and social positioning even when they are not applied directly. The massive expansion of psychiatric pharmaceuticals since the 1970s and the industrialization of clinical medicine also contribute to the cultural and professional uptake of psychiatric labels (Dumit, 2012;Horwitz, 2002). Innovation in psychiatric drug therapies is driven by private, pharmaceutical companies which are concerned, as Joseph Dumit reminds us, with ''the largest possible market'' (2012, p. 5). One key feature of pharmaceutical success is ''personalizing the risk,'' wherein we see it as our job to act on the potential for smaller and more distantly futuristic illnesses -we should ''ask our doctor'' about X pill, consider how we might have this disorder or that impairment (Dumit, 2012, p. 6). Government agencies hand over psychiatric research to drug companies to cut costs, privatizing and individualizing treatment approaches to mental health.
All of these shifts in psychiatry's scope, content, and reach are part and parcel of the neoliberalization of economic markets, political systems, and disciplinary regimes. Although neoliberalism is often conceptualized as simply an economic ideology defined by market deregulation, which has steadily gained global hegemony since the 1980s, Foucault, Rose, and Clarke all illustrate the ways in which neoliberalism has also affected knowledge systems. The neoliberalization of psychiatry involves the rise of clinical trials, privatized and market-driven approaches to treatment, and the individual compulsion to become a healthcare consumer in order to treat potential disease. The shift from discipline to control, from medicalization to biomedicalization, and from norms to optimization is part and parcel of a broader shift in political, economic, and epistemic logics.
The literature on biopolitics, neoliberalism, and the optimization of life suggests that we have moved past the discrete power harnessed by the categories of abnormal/normal into an era in which we all strive for an enhanced scale of normality using technoscientific means. And yet, the case of the DSM-5 suggests that some elements of this argument may be too totalizing. Rather than seeing the compulsion to 'work on the self' as an inherent byproduct of the biomedicalization and neoliberalization of psychiatry, the DSM-5 debates reveal complex challenges to these constructions of optimization and abnormality. In these debates, many commentators pine for an idealized era when the normal and abnormal were ontologically differentiated in binaristic terms. We suggest that this desire to salvage normality from the ambiguity of the norm and the expansion of psychiatry's domain over human conduct constitutes a critique of the neoliberalization of mental health and the biomedicalization of everyday life. We demonstrate how this critique of biomedicalization also reinstates the normal/abnormal binary through its nostalgic constructions of 'human nature. ' Analyses of biomedicalization and contemporary biopolitics tend to emphasize high-tech interventions and the production of patients through sci-fi-like means: humans become calculable, measurable, imaged, and molecular. And yet, most patient interactions with biomedicine proceed less fantastically. The work of biomedicine is more saturated with everyday 'normality' than with wild technoscientific futures, even as those futures work themselves into our conceptualization of normality. As Wayne Brekhus writes, ''The study of social life often neglects the ordinary in favor of the extraordinary… Given that social life is so rarely exceptional, the paucity of research on the mundane is an epistemological blind spot' ' (2000). We take up Brekhus's call to study 'the ordinary' underlying the DSM-5 debates. Brekhus writes that ''The marked is heavily articulated while the unmarked remains unarticulated,'' which allows it to escape analysis, despite its deep entanglements with the marked. Our focus on normality in debates about pathology allows us to bring forth the unmarked foundation of psychiatric knowledge, and therefore to temper and more deeply contextualize some of the claims of the Foucauldian literature while still taking account of the structural shifts it identifies.
We are not the first, however, to attend to shifting conceptualizations of the normal. Disability scholars have been particularly attuned to the operations of 'normality' and its historical shifts. Waldschmidt (2005) agrees that normality is now dispersed across statistical distributions rather than located in rigid binaries, but she also argues that in the case of disability and particularly prenatal genetics, ''…normativity peeks out from behind the friendly face of flexible normalism' ' (p. 196). When in doubt or fear, we sink back into binary constructions of normality. Other scholars point out that disability is always present -as an absent, undesirable Other -in discourses about healthy, 'normal' families and citizens, in everyday anxieties about such popular topics as thinness and aging (Campbell, 2005;Carey, 2009;Kafer, 2013). Constructions of disability haunt constructions of normality, and vice versa, each endlessly hailing the other.
Additionally, disability scholars have focused on 'normality' as a disciplinary regime, despite the fact that, as Kafer points out, impairment and disability are part of everyone's experiences of being human, making pure, essential 'normality' unachievable (2013). In his work on ''compulsory able-bodiedness,'' McRuer suggests that the human body itself is conceived of as a normative machine, and bodies outside of this functional imaginary simply do not exist: ''In a nutshell, you either have an able body, or you don't'' (2010, p. 371). This system seems to emanate from ''everywhere and nowhere,'' giving it greater power as its operations appear natural rather than coercive (McRuer, 2010, p. 372). Drawing on Judith Butler, McRuer identifies the unachievability of able-bodiedness: ''Able-bodied identity and heterosexual identity are linked in their mutual impossibility and mutual incomprehensibility -they are incomprehensive in that each is an identity that is simultaneously the ground on which all identities supposedly rest and an impressive achievement that is always deferred…'' (2010, p. 372). 'The normal' is incoherent: it secures our social imaginary of naturalness, while slipping repeatedly as a hegemonic system because it can never fully contain the disabled and queer lives that are produced as Other. In a sense, the normal is empty. It does not contain positive meaning, but forecloses other possibilities of life. It is in this sense -the need to protect normality despite its emptiness -that 'the normal' becomes such a powerful force in psychiatry.
Detailing the history of Freudian psychotherapy, Eva Illouz writes the following about the twin figures of normality and pathology in psychiatric knowledge: What made 'normality' such a powerful cultural category was that its referent and signified were left unspecified… at the same time that 'health' and 'normality' were posited as the goals toward which narratives of selfhood should be shaped, the very conceptual structure of psychoanalysis prevented ascription of clear cultural content to these two categories, with the result that they were able to accommodate any and every individual or behavior… Ideas may be particularly forceful precisely when they do not have a clear empirical content and when they work negatively, that is, when their meaning derives not from what they prescribe but from the incessant play of oppositions they create… Health and morality were powerful in this way because they were negative cultural categories. (2008, pp. 44-45) Although 'normality' is the presumed category that undergirds psychiatric classifications, it does not capture a set of established meanings. It is for this reason that Illouz describes 'normality' as operating negatively, not through its containment of cultural meanings, but through its character as not-something-else. It is this negative construction in psychiatric knowledge that allows normality to operate as both a critique and celebration of medicalization. For Frances and those who wish to 'save normality,' normal requires no work: it is an unmarked category ontologically distinct from the abnormal, harkening back to simpler times when binaries were clear and secure. For those who see hope in psychiatric diagnosis, normal is an achievement -possible only through the work of optimization and medicalization.

Assembling the Archive
In this paper, we analyze the DSM-5 and psychiatric diagnoses as cultural objects. We are interested in understanding psychiatry as a ''significatory field'' (Steinberg, 2015, p. 118) in which meanings about humanity, normality, pathology, and social reality are produced and disputed. In order to examine the ways in which the DSM-5 debates throw psychiatric meanings into new light, we compiled an archive of newspaper, blog, popular book, and website content related to this controversy. Using Lexis Nexis, we conducted a random search for news related to the DSM-5, pared down the list to those articles that dealt with the DSM-5 debates in some way, and then sampled every third article. We supplemented this random sampling with a more purposive sample, based on our initial reading of the data. To our archive, we added content based on our own Google searches of DSM-related news and blog postings in order to include more lay commentary that did not make it into mainstream news sources. In total, we analyzed 176 articles, along with two popular books about the DSM-5 controversy (Allan Frances's Saving Normal and Gary Greenberg's The Book of Woe), as well as selections from the DSM-5 itself, the APA website, and the National Institute of Mental Health website. We then coded the data according to qualitative themes discovered upon multiple readings of the material. Although we coded for many themes, we focus here on the following codes: 'public anxiety,' 'identity,' 'individualization of illness,' 'inflation/expansion,' 'shrinking diagnostic category,' and 'thresholds.' The data that we draw on for examples throughout the paper emerged primarily from these six categories. Analyzing media representations of the DSM-5 controversy allows us to demonstrate how debates about pathology problematize the figure of the normal, disrupting social scientific theories of our 'optimized' future.
Although common in cultural studies and related fields, analyzing newspaper and blog data is not a widely accepted method in the social sciences. In their paper analyzing the readers' comments section of a New York Times article about autism during the DSM-5 debates, Barker and Galardi (2015) make the case that sociologists should pay more attention to ''the world of participatory journalism'' (p. 7). Online news is central to the public's understanding of scientific claims and controversies, and features such as comment sections and blogs reveal lay reactions to biomedical shifts. It is precisely this type of lay reaction that we seek to capture through assembling these data. Although we do not include comments sections in our own data, our archive is layered with journalistic accounts, patient and parent blogs, psychiatric expert accounts, professional books, and institutional press releases. This breadth allows us to highlight the discrepant reactions to biomedical expansion -we are able to draw both from cases in which commentators jockey for continued inclusion of their categories, while also pulling from news sources focused on push-back against the proliferation of categories.
Despite its breadth, we submitted our archive to a diligent, multi-stage process of qualitative coding: we first read through the data to discover substantive themes, we then developed theoretical codes based on the data and our knowledge of the adjacent social science literature, and we then returned to the data to conduct precise, line-by-line coding. Our analysis is the result of this multi-tiered coding process, and we present news, blog, and book data throughout the paper to illustrate our theoretical assertions. Assembling the diverse textual elements of a public scientific debate such as this one allows us to highlight the uneven terrain of large-scale shifts such as biomedicalization.

Diagnostic Anxiety
A great deal of anxiety about the authority of psychiatrists and diagnostic labels to police and erase 'normality' bubbles up in the DSM-5 debates. Concerns about the disappearance of the figure of normal in an era of sweeping mental medicalization communicates unease about how diagnostic discourse circulates more broadly. In an article called ''Where Have All the Normals Gone?'' Allen Frances argues that, ''The boundary between psychiatry and normal is fuzzy and elastic, with no bright line to say who is sick and who is well'' (2013). A Newsweek science writer asks, ''If there is a pill to cure all ills, will there no longer be such a thing as a healthy mind?'' (Ericson, 2014). A psychiatrist and novelist writing for the Huffington Post reports that, ''There's virtually no more 'normal,' and common 'unhappiness' is now viewed as a treatable condition'' (Rubinstein, 2013). What this concern with proliferating disease categories paradoxically brings to the fore, then, is the besieged category of normality, which is represented as both utterly undefined and critically important for humanity.
In these debates, we were struck by how clear it was that 'normal' served as an empty category -not a set of behaviors, but simply the absence of disease symptoms or risk profiles. Bruce Cuthbert, one of the leading biological psychiatrists -and a leader in the National Institute of Mental Health -who rejects diagnosis in favor of a biology-based psychiatry, explains this slippery distinction in an interview: The DSM doesn't really say much about what's normal, it just says what's abnormal,'' Cuthbert says. If mental illness is on a gradient, ''it's not that you're healthy until you're sick and have a disorder, in the sense that you're healthy until you have the flu, and then you have the flu… what's the opposite of being depressed? There isn't one. What's the dimension of that? So you're 'fine.' There's no measure of what it means to be fine and to be depressed. (Voosen, 2013) Cuthbert and other commentators in the DSM-5 debates ask us to consider precisely where 'fine' is. What are its contours and its contents? Diagnostic criteria and psychiatric measurement instruments are supposed to help define these boundaries, but as professionals in these fields repeatedly point out, such tools are really geared toward finding disorder. Because the DSM-5 is purportedly further loosening diagnostic criteria, the domain of normal is shrinking. Everyday distress, discomfort, and sadness are snatched away by diagnostic labels. Darian Leader, a psychoanalyst and author, writes for The Guardian that, ''People with no signs of distress may be encouraged or coerced to have therapy or take medication, with diagnoses such as 'psychosis risk syndrome' being made even if a psychosis has not appeared. With the ramification of diagnoses, stigmatisation and discrimination would snowball. After DSM-5, no one will be normal again' ' (2010). Even if you are not yet mentally ill, the fear is that you will be diagnosed with a 'risk' for mental illness, impeding on normality even further via anticipation of pathology. The pervasive diagnostic anxiety surrounding DSM-5 does not exactly suggest that 'the normal' should be defined -the way Bruce Cuthbert might argue it should be. Rather, what becomes clear is that normal is under siege.
Others argue that psychiatry's lack of attention to what makes up normality is precisely the problem. In these accounts, not only does the dismissal of the positive construction of normality leave us culturally empty, but it also renders us exploitable by drug companies and other disease markets. For example, one family therapist and author laments that, ''The manual… tries to categorize many unsettling but normal life events, such as death, in much the same way that medical science categorizes physical illnesses… this misleading approach will cause therapists to spend even less time talking with patients, and to recommend more drugs in our overly drug-dependent society'' (Smullens, 2013). Gary Greenberg, a psychotherapist and staunch critic of the APA, describes the DSM as ''launching diagnostic epidemics on an unsuspecting public'' (2013, p. 98), and Allen Frances tells Mother Jones that small changes in DSM definitions will create millions of ''anxious new patients'' for psychiatry to bill (Mechanic, 2013). It is precisely the emptiness of the category of normal which allows this expansion to take place, making more and more of us vulnerable to psychiatric and pharmaceutical profiteering.
The professional and popular discourse around DSM-5 diagnostic categories is uneasy and suggests that psychiatry has failed to provide meaningful labels for our suffering. This anxious DSM-5 discourse posits normality as a tormented figure, humanity's disappearing guidepost. Psychiatric pathology is ''leaking into normality,'' and ''shrinking the pool of what is normal to a puddle,'' according to one science writer (Kelland, 2010). Pathologies exceed their bounds and pollute normality. A New York Times op-ed by an activist critical of psychiatry asks, ''Do we want a society in which each and every flaw of character is understood as a disease?'' (Davidow, 2013). Here, anti-psychiatry critics meet psychiatrists, therapists, and mainstream science writers: medicalization expands even as medical authority appears to shrink, resulting in anxiety about the cultural stakes of diagnosis and what kinds of meanings are conferred on the human condition. In the case of American psychiatry, then, when medicalization and pharmaceutical profit are critiqued for spinning out of control, diagnostic authority falters, and human 'normality' is the ultimate sufferer.

The Figure of Normality
According to the DSM-5 debates, then, a shrinking reservoir of normal lies underneath these expanding diagnostic categories. In this section, we highlight the two primary ways in which DSM-5 critics construct the normal/abnormal binary. Some commentators, led by Allen Frances, present the underlying figure of normality as a primordial or 'natural' human, uncontaminated by biomedical expertise. This constitutes a strange reversal, wherein the proliferation of biomedical categories creates nostalgia for an imagined, natural past rather than hope for a technoscientific future. Another group of commentators, spearheaded by psychologists and therapists critical of biological psychiatry, also wants to protect normal from psychiatric intervention, but without the call to premodernity. In these critiques, psychiatry is imagined to pathologize spontaneous human emotion and resilience. For this second set of critics, the scienticization of human emotion is called into question, such that unmediated human responses are valorized. In both cases, these commentators engage a strong critique of the neoliberalization of psychiatry, with its incessant quantification and drug profiteering. Rather than progressive and preventative, disease 'risk' here is branded a psychiatric hoax. As biological psychiatrists seek to locate disorder in the genes and brain via heavily funded national projects, much of the public debate surrounding DSM-5 actually calls for the return to innate human capacities, unencumbered by psychiatric knowledge. Although some critics idealize an imagined pre-modern self, and others focus on unmediated human emotion, we show how both groups subtly reinstate a binaristic notion of normality when they eschew discourses of 'risk' and attempt to stave off over-medicalization. Normality is constructed slightly differently in each critque, but both attempts to save it end up binarizing normality from abnormality. Allen Frances's call to arms against the DSM-5 provides a useful starting point for explicating the discourse of innate human potential, the first (re)construction of normality that we pinpoint. In his 2013 book, Frances argues that we are ''short-circuiting'' our evolutionary process by medicating ourselves and closing off the possibility of ''natural healing'' (p. 32). Medication, he argues, interferes with our inborn homeostasis, which is the ''master regulator'' of our bodies (p. 31). In the wistful, romantic language typical of those who argue for a primordial, pre-medicalized self, Frances describes the human self as a complex and ''exquisite equilibrium'' (p. 31). And Frances is not the only psychiatric expert constructing innate, emotionally stable humanness as the foil to our overly diagnosed, neurotic modernity. As one blogger wrote in a newspaper opinion piece, ''Perhaps we are not here to be happy. Perhaps instead we are here to become whole where wholeness means being able to deal with the ups and downs… Allowing space for and recognition of these processes is not only integral for personal growth, but, in the longer term, for the development of our species'' (Fitzgibbon, 2013). Drawing heavily on essentialist, evolutionary discourse, this set of commentators posit that psychiatry is responsible for the destruction of human capacity, both in terms of spontaneous individual responses and in terms of the course of human history. Part of the work of pushing back against diagnostic expansion, then, is not only to 'save normal,' but to save human evolutionary capacity. This language about the roots and inborn capacities of humanity typifies those commentators who pine for a primordial self who is quintessentially 'normal,' underneath our overmedicalized veneers.
For the second re(construction) of normality we identify -commentators who fear the flattening of human diversity via the psychiatrization of society -'normal' emotional responses to difficult life events should be salvaged from over-intervention. In the words of a group of British psychologists who wrote an open petition against the DSM-5, ''We believe that the protection of society… should be prioritized above nomenclatural exploration'' (Elkins, 2011). Contributing to the discourse of normality as besieged by psychiatric experts, this letter suggests an urgency to protecting normality, that we are about to be swept away on a tide of psychiatric categories that will undo our ability to deal with the 'ups and downs' of life. The letter further accuses the APA of ''…continuous medicalization of their [patients'] natural and normal responses to their experiences'' (Elkins, 2011). Emotions such as sadness and anxiety, these psychologists contend, are 'natural' to humans and should not be included under psychiatry's purview -rather, these emotions should be 'protected,' left outside the realm of scientific experts. The process of medicalization not only ignores 'normal' responses to experiences, but it impedes the ability of normalcy to exist at all. Sam Kriss, a critic in the UK and one such commentator who fears over-intervention into 'natural' emotions: ''If there is a normality here, it's a state of near-catatonia. DSM-5 seems to have no definition of happiness other than the absence of suffering. The normal individual in this book is tranquilized and bovine-eyed, mutely accepting everything in a sometimes painful world…'' (2013). Here, one of psychiatry's central problems is its construction of normality as an inability to feel anything, as absence itself. The human is flattened into nearnothingness precisely because any emotion -especially that which is effusive or excessive -is potentially abnormal and in need of intervention. In this second set of critiques, normal is not pre-modern, but it is a 'real' set of emotions that exists underneath our interventions, in need of salvaging from psychiatric erasure.
In the Introduction to the DSM-5, the APA itself attempts to curtail both sets of critiques by defining normality as a zone of accepted responses to life circumstances: ''An expectable or culturally approved response to a common stressors or loss, such as death of a loved one, is not a mental disorder. Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders…' ' (2013). And yet, while the APA defends itself against claims that it may be pathologizing 'deviant' figures (such as gay people or the devoutly religious), the primary claims of DSM critics revolve around the figure of the normal rather than the deviant. It is not the social deviant that Greenberg, Frances, and others seek to protect, but rather, humanity itself. Unlike other eras of DSM debates, the embattled figures here are not victims of social marginalization, but the everyday person whose 'self-healing' capacities are endangered by psychiatric medicalization and its erosion of normal. As one journalist wrote, ''Anyone who crosses their fingers for luck, for example, has had a taste of obsessive compulsive disorder… Mental illness is an intensification of normal behaviour, not something different from it in kind'' (Stevenson, 2013). Thus, while the APA attempts to fire back against its critics by stating what is not a mental disorder in the opening to DSM-5, APA authors miss the mark -the figure in need of protection here is not an ostracized Other, but the natural capacity inside each 'normal' one of us.
And yet, in the DSM debates, there is very little discussion of more severe disorders like schizophrenia. Critics from both groups of commentators focus almost exclusively on the APA's assault on 'normal' people, like 'us.' Even Temple Grandin, an autism advocate, speaks more about high-functioning people with autism, those whose behaviors are eccentric versions of 'normal' behavior (Grandin and Panek, 2013). For Frances and likeminded critics, while we are supposed to return to some pre-modern 'natural' state in order to protect ourselves from psychiatry's grasps, this rejection of psychiatric labeling and intervention is really only for those of us already considered 'normal' to some degree, those of us imperiled by psychiatry's over-extension into 'our' minds. Similarly, for those critics who valorize emotional essentialism, 'saving normal' means salvaging unmediated mental responses to life events. While this response is not pre-modern, it is premised on the idea that normal human function can be resumed without intervention. The spontaneous human emotion to be saved is within a presumed normal range. Unlike anti-psychiatry critics of the 1970s, for example, who called for the (institutionalized) mentally ill to unshackle themselves from psychiatric authority, the current wave of psychiatric unease is very clearly aimed at 'the worried well.' Thus, while the APA attempts to make us all atrisk for mental disorder, the DSM-5 debates suggest that this interpellation fails. In fact, psychiatric critics of both camps reinstate a sharp boundary between normal and abnormal, rallying around and seeking to protect normality as a fundamental feature of the human, but specifically the human who is not 'really' mentally ill already. Reinstating the binary suggests that we do not need psychiatric labeling and medication, as normal is underneath our over-psychiatrized worries; if abnormality were to be upheld as a range or spectrum, we would be always-already under psychiatric purview (as in the DSM-5). It is in this way that critiques of psychiatry's neoliberalization rely -however implicitly -on the secure grounding of the normal/abnormal binary. Essentialism and binarization, in these debates, become the discursive foils to neoliberalization and risk.

Normality and the Contingencies of Optimization
But how are these constructions of normality mapped out on the terrain of disorder itself, given the DSM-5's impact on sufferers and their families? Now that we have accounted for the faltering authority of diagnosis in the case of DSM-5 and the construction of the figure of normality as either essential and salvageable, or pre-modern and anti-technological, we consider two prominent cases in the DSM-5 -autism spectrum disorder (ASD) and depression -in order to think through disparate responses to the biomedicalization and neoliberalization of psychiatry. Despite the strong surge of commentary against psychiatry, of critics wanting to save normal, others still want to achieve normal via psychiatrization. It is this tensionalways present under conditions of biomedicalization -that we seek to draw out in this section. While scholars of neoliberalism and optimization often paint this achievement of normality via technoscience as totalizing, we focus here on disparate cases in order to demonstrate the lumpiness and inconsistencies in biomedicalization and in the neoliberal mandate to self-optimize. We consider the figure of normality in the cases of autism and depression because they offer opposite examples -in the case of autism, the diagnosis is defended (Barker and Galardi, 2015), while in the case of depression, the diagnostic category is harshly critiqued for being too expansive. Depression critics fall in line with both sets of 'normal saviors' outlined in the previous section, while autism critics hope to achieve normal via science. While the defenders of autism are mostly parents and people with Asperger's diagnoses, the critics of the expansion of depression are primarily therapists and psychologists, plus a handful of ''grievers'' who wrote blogs and opinion pieces about their experiences in order to defend the ''natural'' grieving process. In both cases, the nature of normality is problematized by commentators in the DSM-5 debates. With autism, achieving normality must involve keeping the label in order to hold on to services that improve behavior and functioning: normality via optimization. 2 With depression, achieving normality involves casting off psychiatry's label, eschewing intervention. Here, autism demonstrates hope for psychiatric intervention, while depression demonstrates its failure. Both occur in the cultural context of biomedicalization, risk enhancement, and calls to optimize our health, and yet the outcomes are different. Our analysis suggests that the unfolding of and investment of citizens with optimization narratives and biomedical logics is not an even or secure process.
In an effort to curb criticism of its revisions (Pickersgill, 2013), the APA invited public comments on its 2010 draft manual, which led to the posting of 8000 comments on the APA website. 3 The proposed revision that attracted the most attention online was a change to autism and Asperger's disorders, which transformed these separate conditions into one ''spectrum'' disorder. According to Gary Greenberg (2013), a full 2000 (25 per cent) of the online comments were from families of children with Asperger's, pleading for their diagnoses not to be dropped from the manual. Indeed, this pleading became a major source of popular news interest around the DSM-5. Critiques of ASD were not limited to discussion boards. In a petition to the APA, the Asperger's Association of New England wrote that the 2 Access to interventions for people with autism is a fraught political issue. For some neurodiversity activists, autism requires no interventions. Rather, autism is a 'natural' expression of neurodiversity which should not be the target of normalization efforts (Bumiller, 2008;Silverman, 2008;Orsini, 2009). Other people with autism (or their parents) access only mainstream behavioral methods, and still others access more 'biomedical' or alternative therapies. In fact, it is well documented that parents of children with autism are quite hybrid in their approach to interventions, combining a social and medical model of disability (Silverman, 2012;Hart, 2014). We use 'optimization' simply to signal the fact that it is quite common for people with autism (or their parents) to access some form of intervention, in order to improve behavior and thus better the chances of inclusion. And in fact, this was a major feature of the debates we tracked. Parents of children with Asperger's were concerned that losing the label would delimit their opportunities to access resources for their children. 3 These comments are not part of our analysis.
Asperger's diagnosis is essential to the ''established sense of community precious to already diagnosed individuals and families,'' as well as to ''maintain the hard-won understanding of the label in the population at large'' (quoted in Hazen et al, 2013, p. 742). As these comments illustrate, the DSM-5 debates have brought the complex relationship between biosocial groups and diagnosis to the fore of psychiatric and public attention, raising questions about the ways in which resources and identities are inextricably linked to diagnostic categories. Part of the public anxiety surrounding the DSM-5 release, then, concerns the APA's power to haphazardly snatch away diagnoses with each iteration of the manual, a theme that returned repeatedly throughout news articles and blogs (e.g., Stevenson, 2013;Lutz, 2013). The APA's move toward a spectrum diagnosis for autism is at the center of these struggles.
Depression also plays a central role in the DSM-5 debates. Therapists, bloggers, and science journalists have been especially critical of the changes to Major Depressive Disorder (MDD), which has expanded in the DSM-5 through the removal of the 'bereavement exclusion,' which previously barred practitioners from diagnosing someone with depression if they had lost a loved one in the past two months. With the removal of the bereavement exclusion, many argue, someone could be diagnosed as 'depressed' and prescribed medication even if their partner of 50 years died unexpectedly the week before. Because of this, psychiatrists and therapists of various backgrounds pounced on the APA for medicalizing grief, for pathologizing what is surely a natural response to losing a loved one. As one family therapist states, ''Now the newly published DSM-5 has taken this growing 'take a pill and fix it' approach to even more dangerous ends. Normal sadness after the loss of a beloved partner falls under the heading of clinical depression'' (Smullens, 2013). Much of the DSM-5 debate was occupied with outcry about this decision. Psy-experts, newspapers, and bloggers called the decision ''shameful,'' and accused the APA of pandering to the pharmaceutical industry. In these critiques, grief is often represented as a fundamental feature of humanness. According to a social work professor and expert on grief, psychiatrists are trying to replace medicine with human support and comfort: ''We have to let people go through the dark night of the soul… People can get help without being labeled mentally ill.
That's what churches are for, that's what community is for, that's what spiritual leaders are for'' (Townsend, 2013). News articles reporting on the removal of the 'bereavement exclusion' are often accompanied by testimonials of loss and pleas to 'protect' the grieving process.
So, what are the figures of normality that underlie 'autism' and 'depression' in the DSM-5 debates, and what does this mean for how the meanings of their attendant interventions are reimagined? In the case of autism, we do not see this call to return to some natural, innate humanness -calling for the essence of normality would mean that people with Asperger's would no longer be recognizable to the system of service and care. Thus, autism presents a more classic case of biocitizenship -or 'diagnostic domain defense' (Barker and Galardi, 2015) -in which groups seek to protect their illness labels in order to be recognized as citizens in need of services, especially for those with more 'high-functioning' forms of autism. The discourse around depression looks quite different. Here, normality is under assault, and we are called on to protect it by rejecting psychiatric intervention and guarding our inner human resilience, like Frances and other saviors of 'normal' outlined in the previous section. Both sets of discourses make claims about normality. The debates around depression make positive claims about an innate normality -grieving is normal, death is normal, sadness after loss is normal. The debates around autism suggest that changing 'Aspies' into 'normal' citizens would mean losing resources and recognition. Instead, normal is the end goal of a set of interventions, a future horizon. For autism, enhancement is normality -'the normal' is something to be achieved. For depression after grief, enhancement would mean a loss of normality -'the normal' exists inside of us, covered over by psychiatric intervention.
In the case of depression, the expanding diagnostic category propels a critique of overmedicalization and pharmaceuticalization. It appears here that psychiatry has failed to convince us to pursue 'health' via psychiatric intervention. As one psychiatrist quipped in the New York Times, ''It is shameful that organized psychiatry is so out of touch with such a fundamental, and often prolonged, human process as mourning. Only the pharmaceutical industry could be happy with such a decision'' (Livingston, 2010). Because grieving is offered here as a normal part of any person's life experience, something ''fundamental'' to being human, psychiatric intervention is constructed as a farce, a ploy for profit. This normality that is the supposed core of any griever suggests an opposite abnormal: two clear figures, two poles. The DSM, on the other hand, suggests that the normal/abnormal is on a spectrum, that all grief reactions should fall along a range of abnormality to some degree, such that psychiatric intervention is necessary. In order to avoid the over-medicalizing work that this continuum accomplishes, the DSM's critics reinstate the normal/abnormal binary, arguing that we should protect one side: normality. Critics cited in mainstream newspapers accuse the APA of evacuating the normality of grief, which is part of the ''human experience,'' through its construction of this risky, pathologized spectrum (Deardorff, 2014). Grievers are 'assaulted' by American psychiatry, smacked with a label while toiling through 'natural' processes. This group should be protected from psychiatric labeling and prescribing.
As Allen Frances writes, ''Grief is an inescapable part of the mammalian experience and a necessary correlate of our ability to attach so strongly to other people'' (2010). Rather than a misfiring of neurons, a trauma in the family, or a genetic disorder, grievers here are constructed as evolutionarily correct, as 'standard' humans. This group should not be given anti-depressants, warns blog post after blog past. Other critical therapists like Sarakay Smullens sound the alarm that the ''take a pill and fix it'' mentality of American psychiatry will have ''dangerous ends'' (2013). Critics point out that a secure space of normality within the DSM framework is elusive: the DSM-5 spectrum of abnormality and risk is created precisely so that psychiatric intervention becomes the inescapable 'choice.' Importantly, these defenders of natural grief do not critique the use of depression as a diagnosis in general. The seriously depressed should still be identified, diagnosed, and treated, they contend. Grievers, however, constitute a category of normality that should not be impeded upon with psychiatric knowledge or pharmaceutical interventions. Thus, the binary between normal and abnormal is reinstated here -grief is normal, depression is not. The debates around autism, on the other hand, tend to construct this figure of normality differently. While Frances and other defenders of 'the normal' critique parents of autistic children for holding on too strongly to their label, parents fire back by showcasing the loss of services and care that would come with placing autism on the scale of 'normality': ''Ursitti, who has a daughter with Asperger's and a son with severe autism, feels this is already happening: 'If we have this national perspective that autism is a blessing, that it's not a crisis, the ones who will lose out are the expensive ones, the severe ones''' (Lutz, 2013). Thus, for many parents vocal in the DSM-5 debates, returning to a natural, innate normality on a 'spectrum' would mean the elimination of services. For these parents, primordial, innate normality is a dangerous construct. In order for interventions to exist, normality must be situated on a future horizon rather than constructed as the obscured center of each human.
Defenders of the Asperger's diagnosis asked for their label to be kept not only so that they could hold onto the resources of optimization (e.g. behavioral intervention services), but also because the label is an identity category. In an interview with Newsweek, a 50-year-old man with Asperger's describes exactly this disjuncture in recognition created by the APA's new spectrum categorization: ''While I accept that Asperger's may be part of the autism spectrum as a whole…. I personally do not see myself as autistic in any way'' (Ericson, 2014). Here, accepting the DSM's new terms of recognition would mean a significant shift in identity. Another newspaper article suggests that ''Aspies'' are being demoted to the ''B-List'' of psychiatric disorders (Rogan, 2012), such that the negative effects on resources and identity are overlapping. One mother, lamenting the loss of her child's diagnosis because it will mean loss of therapy and educational entitlements, struggles with the fact that her child is ''no longer autistic'' under the new DSM (Wicks, 2012). For this parent, normality is actually tied to the diagnostic label, because services geared toward optimization are attached to that label. The APA's removal of Asperger's, then, is widely interpreted as a misrecognition and as a potential loss of resources. Recognition and understanding in the community are not simply about acceptance and visibility, but also about the services achieved through those recognition efforts. Loss of identity is linked to loss of the path to 'normality' via services centered around improvement.
The contrasting cases of autism and depression point to the importance of considering what happens to normality and discourses of optimization when diagnostic anxiety troubles biomedical authority. Here, the construction of normality -as either innate or achieved, as a natural foundation of the self or as an end goal of intervention -is critical to understanding how biomedicalization processes unfold. Because normality is an empty category, a shadow figure in psychiatric knowledge, it is malleable and can allow for both critique and celebration of biomedicalization. When biosocial claims require groups to hang on to their diagnostic categories, normality is about potentiality and possibility, about optimizing the future of the patient (autism). On the other hand, when normality is about the inner human, about an internal capacity endangered by intervention, there is little incentive to reach toward optimization via biomedicine (depression). In the case of depression, the DSM-5 debates demonstrate a case in which the call to optimize, to seek a better state of health, breaks down; instead, our better state of health existed before psychiatry, before the reach of pharmaceuticals and psychiatric expertise. The construction of normality as inside of our skin is central to this failure of psychiatric interpellation.

Conclusion
As theorists have long argued, late modernity pushes us away from binaristic categorization to spectrums, from clear boundaries to elastic scales. Control and surveillance therefore operate more diffusely on these scales, capturing us by producing us, not bearing down on us, but constituting our desires, our participation in the minutiae of everyday life. What this means for the relationship between biomedicalization and health, then, is that we are compelled to work on ourselves in the name of optimization and enhancement. And yet, these processes do not subjectivize in unified ways -for example, across lines of gender, class, and race. As Clarke and her colleagues admit, cooptive medicalization and exclusionary disciplining often work in concert to stratify medical services across racial, class, and gender lines (2003). Processes of biomedicalization, therefore, do not unfold smoothly across the participating public sphere. Contestations occur, and the content of those contestations matters for the way in which health, expertise, and normality are constructed. Indeed, Conrad (2007) and others (e.g. Torres, 2014) have shown that demedicalization is an important component of medicalizing shifts, such that social movements and lay actors often push for medical tools, practices, and identities to be reincorporated into the category of normality. Medicalization and de-medicalization may even occur simultaneously, as the invention of new medical tools make certain procedures and knowledge more accessible to non-experts (Murphy, 2012;Torres, 2014). Peoples' involvement with the categories constructed by psychiatry (and their efforts to contest 'normal') feed back into processes of interpellation and diagnosis, reshaping the fields of service provision and advocacy. Ian Hacking refers to this process as a ''looping effect,'' where people react back on the category generated because it affects their self-definition, thus changing the category and its expression (1995,2006). As we have shown, normal is the ghost in the DSM-5 debates and it occupies two positions: for some, it is about a simpler time or an innate human capacity, harkening back to clear demarcations and binaries; for others, normal means seizing technologies and embracing optimization. These are both responses to biomedicalization, and both are important for understanding the uneven operation of power on a complex social terrain.
Although we have made the case that constructions of the normal matter for the unfolding of biomedicalization processes (of which lay responses are a part), we have not claimed to answer the question 'what is normality' in the field of psychiatry. For the defenders of Asperger's diagnoses and the APA, normal is a horizon of future achievement for which psychiatric knowledge and tools are required. For Frances and many of the DSM-5 critics, normal is inside us, it is our natural state as humans, covered over and compromised by psychiatric labels and interventions. For others, who do not necessarily envision a 'natural' state of normal residing somewhere inside of us, there is nonetheless a kind of natural division in the world between normal processes (like grief) and abnormal behaviors (like schizophrenia). These accounts more subtly rely upon a binary between normality and abnormality, but the source of those differentiations is unclear. For some, it is naturalized (in the genes), but for others, it comes from trauma and other extreme experiences -where abnormality might, indeed, arise from being forced to endure abnormal pain and suffering (thus rendering its manifestation rational, even 'normal'). Freud himself blurred these distinctions and nonetheless relied upon them. For him, normality was an end point of 'proper' development, but most people were not able to achieve this. In his essays on sexuality, inversion (homosexuality) is the opposite of 'normal' development, and yet all 'normal' people have elements of such perversion (Freud and Strachey, 1962). Perversion is not only common, but almost normal. For Freud, then, normalcy is an achievement through psychoanalysis, but it is also a spectrum, which moved away from the dichotomization of normal/abnormal. It is because normal is a negative category in psychiatry that its meaning oscillates so dramatically in these debates. We have tried to excavate these different figurations of normal to unveil the ways in which psychiatry both relies upon and troubles the binary between pathologization and normality, and between optimization and essentialization.

About the Authors
Paige L. Sweet is a PhD Candidate in Sociology at the University of Illinois at Chicago. Her work focuses on trauma and biopolitics in the U.S. feminist anti-violence movement.
Claire Laurier Decoteau is an Associate Professor of Sociology at the University of Illinois at Chicago. Her research focuses on the social construction of health and disease, the politics of knowledge production, and peoples' grounded experiences with healing and health care systems.