William M. Briggs

Statistician to the Stars!

Everybody Has A Mental Disease: Diagnostic and Statistical Manual 5

I am so far Up North that I heard a radio interview with Uncle Ted Nugnet on the best kinds of arrowheads to bring down feral pigs. Internet still only once daily mlh


Step into my parlor, and let me wave my diagnosticulator at you. OK, let me just consult the book.

Ah! Just as I suspected. Since you yelled at that IRS agent during your audit, we know you suffer from temper dysregulation disorder with dysphoria. This is normally seen in children, and is what we used to call a temper tantrum. Actually, it is a mental disease.

When seen in adults such as yourself, it requires medication, if not confinement. It’s for your own good.

And speaking of children, you have some, do you not? With a guardian such as yourself already known to be suffering from a mental disease, your children are at risk. In fact, I’m going to write a prescription for Psychosis Risk Syndrome. You just give them these pills, OK?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-V is on its way. Just as did DSM-II, DSM-III, and DSM-IV, the fifth entry in this best seller from the American Psychiatric Association will expand the number, kinds, and ranges of mental disease.

Thus, the APA will have fulfilled at least one of its functions: providing job advocacy for its members.

As in previous editions, we can predict that the creators of the maladies will be as certain sure that the diseases they discover will be just as real as the old diseases they discovered and said were real, only to later say that they were not.

For example, homosexuality, which used to be a mental disease classified by the DSM, is now normal. In DSM-IV, “problems with law enforcement” was a disease, and in number five, it won’t be. Why? Because of “cultural issues”. Cancer is cancer whether you are Chinese of Zimbawayan. But a mental disease can depend on where you live?

Anyway, now “heartache over a lost spouse” will be a disease “Suck it up, Bob. Everybody dies. What made your wife special? Walk it off before they come at you with the nets.”

According to an official draft which was released in February, “internet addiction” nearly made the cut. But the consensus committee to develop a consensus—all science is done by Consensus nowadays; didn’t you know?—thought they couldn’t quite get away with this one.

Still, it was too sexy to ignore. Reports are that it will be relegated to the Appendix. As if that will stop shrinks and social workers from making the diagnoses.

Even if they cannot (yet) officially use “internet addiction”, they can still take somebody’s iPhone from them, and if those deprived squabble, they can be hit with “miscellaneous discontinuation syndrome.”

Is it merely your malcontented author complaining, or is there something untoward occurring in the ranks of the white-coated lithium prescribers? After all, we know more about the brain and its functioning now then we knew when the last manual appeared in 1994. Shouldn’t these advances be incorporated?

Professor Til Wykes from Kings College London coauthored an editorial in the August issue of the Journal of Mental Health arguing that DSM-V is “leaking into normality. It is shrinking the pool of what is normal to a puddle.”

Docs at Psychiatric Times, social workers at New York University, and others are are writing in to say, “Slow Down.”

We can visualize the so-called progress of the DSM with this cartoon, which shows the range of human behavior.

At the extremes, people are considered, or actually are, nuts. But as time progresses, what used to be considered eccentric, is viewed as abnormal and in need of medicating, or at least worthy of employing members of the APA to treat.

Nobody, not even the APA, disagrees that, according to the progressive editions of the DSM, a narrower and narrower range of behavior had been labeled “normal.”

If this trend towards limiting acceptable behaviors continues, psychitary will soon be indistinguishable from psychoanalysis or scientology, systems in which it is believed everybody suffers and must be “made clear”, and where only occult experts can guide one on the path to enlightenment.

17 Comments

  1. A straw in the wind? I saw an article in a British paper – can’t remember which – complaining, if I may paraphrase, that those loopy Americans were going to impose their loopy definitions of loopiness on the whole world, which would be loopy to accede to such grandiose loopinosity.

  2. Anyway, now “heartache over a lost spouse” will be a disease

    It actually makes a certain twisted kind of sense when you realize that DSM is not actually used for diagnosis: it’s used for billing insurance companies.

    So if Bob wants to have an expensive therapist listen to how much he misses his wife, there’d better be a mental condition and a billing code to go with it; otherwise, a bill for $200 per hour will greatly add to his heartache.

    My main beef with DSM V is that they left a condition out – controlling personality disorder. Then again, the omission is understandable when you consider that 90% of mental health practioners and 100% of political figures suffer from this condition, whose main symptom is the irrational desire to control small details of other peoples’ behavior.

  3. Clearly the idea of normality is crazy.

  4. I second xj’s point that expanding the realm of abnormality is primarily a way to justify billing insurers for the treatment of more stuff.

    But if government can force us to wear helmets because the cost of treatment for a smashed-up skull is shared, what will happen when certain parenting methods are found to be associated with one or more treatable DSM categories?

  5. For anybody interested, a very good* book that explains the basics of psychology is: “Your Inner Child of the Past,” by W. Hugh Missildine, first published in 1963. Here’s a link: http://www.amazon.com/Your-Inner-Child-Past-Missildine/dp/0671211471

    Its out of print, but addresses a number of “everyday” maladies such as perfectionism, etc. that most are familiar with. The developmental sources/causes are summarized with examples & then, shocking by todays’ standards, is guidance on how one can work out their issues for themselves. No pills, no advocacy for society to bend to one’s neuroses, etc. How times have changed….

    *I state “good” as this was referred to me by a retiring psychiatrist I happened to meet at the racquetball courts in the late 1980s. He had a practice, and, taught at a local university. He was pretty perceptive (to a degree I found spooky relative to picking up on personality traits in me & others I knew) and asserted that Missildine’s book pretty much summed up everything one needed to know, including him. The rest is just detail only a “shrink” could appreciate, or really needed/s to.

    At any rate, read it & judge for yourself.

    xj: as for the “controlling” personality — that’s a sure symptom of someone that is very very insecure, typically from an emotionally chaotic childhood in which they were emotionally off-balance. Its typical of a lot of psychological issues. Most kids don’t surivive this without emotionally scarring, often becoming the type of personality that tormented them. The need for control is driven by a deep-seated need for the stability they never had, so they live in chronic fear of a stable situation transforming into something unpredicatable (which is why people who fit the general category “controlling” often erupt for no apparent reason when things have been going well for some extended period — their brains are effectively programmed to need the chaos they wanted to escape from and they will create it if the environment doesn’t provide it. Also, check out link at the very end of this.

    “controlling” is often associated with the narcissistic personality/personality disorder & on-line Sam Vaknin (a self-confessed narcissist that hit rock bottom in jail, to read his stuff) has a nice summary: http://samvak.tripod.com/ Its a good reference for the subject matter, but not really well organized for the non-paying audience…but one can scrounge thru & find what’s being sought after.

    The narcissist, by the way (a close relative of the psychopath, both of which have little or no conscience, are very self-serving, and get their kicks by jerking other people around just for the fun of it) are the #1 workplace problem personality — and they often appear, especially to management, as the “glue” holding a problem workplace together. Very insidious (in such an organization a clue is to identify the person in the “eye of the hurricane” of interpersonal discord — that individual is most likely to be the source of the problem & not the source of stability they make themselves appear to be). This is so common & so much a problem in organizations that a number of management books try & address this particular issue & keep getting it wrong. One that made the point reasonably well, especially fr the layperson & manager was: “The Power of Persuasion,” by G. Ray Funkhouser (this was used as a text at Cornell if I recall correctly). This too is out of print: http://www.amazon.com/Power-Persuasion-Guide-Moving-Business/dp/0812913183/ref=sr_1_2?s=books&ie=UTF8&qid=1280842339&sr=1-2

    Put another way, anybody interested in the “win-win” solution (e.g. “Getting to Yes, Negotiating Agreement Without Giving In” by Fisher & Ury) will find this personality to be the antithesis/nemesis of that goal. Books like “Getting to Yes” by authors sequestered in ivory towers are upbeat & positive & stay in print; books like Funkhouser’s “Power of Persuasion” directly address the seamy underbelly of life in the real world, and how to address it to some degree, and aren’t as pleasant (the narcissistic personality type [aka “controlling”] don’t generally ever improve toward a less toxic personality type)…and don’t get read & published as much. M. Scott Peck’s “People of the Lie” addresses the same personality (as does “The Sociopath Next Door”) but from less helpful perspectives relative to what most of us could use.

    Anyone interested in getting the gist of this topic area (psychology/psychiatry) can do a search on-line & review “Attachment Theory” — there’s a lot; even Wiki has some reasonable summary material. Its been found that of the four general categories (secure, avoidant, preoccupied & disorganized) the disorganized accounts for well over 80 percent of bona-fide psychiatric issues of significance (the figure varies with the research approach & sample population, but its always very very high). The rest of us (even those with a “secure” upbringing) have relatively minor issues to contend with, which we can & ought to do on our own without making society at large accountable.

    P.S. — Adults who were children of alchoholic parents endured a very particular type of chaotic childhood & have a very particular set of personality issues as a result. Here’s an unusual website from one of them: http://www.guesswhatnormalis.com/2010/01/do-you-love-someone-with-alcoholic-parents.html Its “unusual” because this blog author is endeavoring to resolve thier issues & help others with the same affliction do so as well. Which is unusual because in modern society the trendy theme is for everybody else to kow-tow to those who are worse off, who are allowed to wallow in stagnant non-development.

  6. From This American Life (the world’s best radio show and podcast) …

    Act One. Psycho Dabble.

    A man fakes his way into an insane asylum by pretending to be crazy, and then can’t argue his way back out.
    From London, TAL contributor Jon Ronson tells the story of a man who hasspent more than a decade trying to convince doctors that he’s not mentally ill. But the more he argues his case, the less they believe him. (25 1⁄2 minutes) Song: “Twisted,” Annie Ross
    http://www.thisamericanlife.org/radio-archives/episode/385/Pro-Se

  7. I seem to recall that, since psychologists generally only see people with mental health issues, they generally come to assume that everyone has mental health issues, but some of us hide it better. That old chestnut comes to mind when hearing about the revisions in the DSM-V…

  8. We’re all bozos on this bus.

  9. As the definition of mental illness is leaking into normality,`does it follow that the puddle that remains of normality is the result of a piddle?

  10. Ken says:
    3 August 2010 at 9:04 am

    …xj: as for the “controlling” personality — that’s a sure symptom of someone that is very very insecure, typically from an emotionally chaotic childhood in which they were emotionally off-balance. Its typical of a lot of psychological issues. Most kids don’t surivive this without emotionally scarring, often becoming the type of personality that tormented them. The need for control is driven by a deep-seated need for the stability they never had …

    Here is where I find psychology so precise and helpful. The four most controlling persons I have ever known all had, as nearly as I can tell, nearly perfect childhoods in very stable homes where they got whatever they wanted. One had a controlling mother, though; and another had a mother who never meted out any discipline at all, and praised him endlessly; a third was a youngest child; and the fourth was an only girl in a family of four. Can psychology tell me anything about the source of their troubles?

  11. Woe betide a person who questions the motivation, the efforts or the expertise of the psychtroopers. If they say that black is white or that you were in NYC when you were in fact in LA it’s best to go along with them.

  12. “If a psychiatrist were to come into this room with DSM-V in his hand, no doubt we should pity the state of his mind; but our primary consideration would be to take care of ourselves. We should knock him down first, and pity him afterwards.”

  13. Regarding KEVIN’s remark:

    “The four most controlling persons I have ever known all had, as nearly as I can tell, nearly perfect childhoods in very stable homes…”

    Chances are that as an outsider you (or any of us) cannot come close to discerning a highly toxic & psychologically damaging parent-child interaction even when it is happening right before our inquisitive eyes. The paper at the link, below, describes this pretty well in everyday terms:

    http://www.thrivetoday.org/Articles/attachment%20articles.pdf

    If its not available later for some reason, it is titled: “Attachments – Life’s Connections,” and is a multi-part series with all parts linked together (author is Chris M. Coursey).

    The gist of that item is that a parent’s interaction with the child needs to be synchronized to the child’s needs & interests at the time. A parent’s loving attention that is provided such that it forces the child to break away, unexpectedly, from play is perceived by the child as disruptive, annoying & inconsiderate. Similarly, a child that desires and/or is receptive to parental attention that the parent ignores is perceived as neglect. When this is an ongoing pattern the child learns that its parent’s attentions relative to its needs & desires are essentially unpredicatable, which by extension makes the parent untrustworthy as a focus for an emotional bond. To a spectator the parent’s behavior appears quite positive…and the spectator will be puzzled as to why the kid turned out to be so controlling.

    An adult work/office parallel to this is presented in the management paper, “Receiving Instrumental Support at Work: When Help Is Not Welcome,” by Janna T. Deelstra, Maria C. W. Peeters, Wilmar B. Schaufeli, Wolfgang Stroebe, Fred R. H. Zijlstra, and Lorenz P. van Doornen; Journal of Applied Psychology, 2003, Vol. 88, No. 2, 324–331. It is available on-line via keyword search, e.g.: http://cyber.gwc.cccd.edu/faculty/sisonio/support.pdf . The findings reflect the title, when employees receive forced help from a manager it is, under predicatable circumstances, perceived negatively (if help really wasn’t needed) to neutrally (when task completion required the intervention). This particular issue is “old” going back, at least, to the 1980s with Quality Circles, various Japanese management techniques, etc. where this specific issue was a common curriculum topic in such training programs (so why it needed formal study & reporting as late as 2003 just illustrates the duplication to be found in management psychology; chances are managers involved in the construction of Egypt’s pyramids figured this out as have successive generations since…but I digress….).

    Without debating the point, there ARE good psychiatrists & psychologists who can consistently diagnose various conditions, many are very good at helping people resolve issues, some very deep seated. Government intelligence/spy organizations apply this same body of learning, often very effectively, in ways most would consider unethical…’nuff on that….

    The point is to recognize that the presence of numerous “bad” practicioners does not negate that fact that the profession–when practiced competently–has a lot of positives to offer. The cliche about not throwing out the baby with the bath water is very apt relative to this realm.

    But there is a sizeable proportion of well-intentioned quacks out there that gravitate to the profession as a proxy for getting the help they need.

    Psychology/psychiatry also a profession with some inherent conficts of interest, with a notable one putting children & youth at greater risk. The generic scenario is a kid brought in for evaluation or counseling and manifesting a problem that is clearly caused by “bad parenting.” As the parents are paying for treatment, and providing the feedback to insurers, etc. on the doctor’s performance, the doctor has strong incentive to treat the child’s symptoms in any way that avoids the real issue — and in the long run this tends to compound the child’s problems (the surge in precriptions of Ritalin to treat hyperactivity, etc. is partly a symptom of treating the child to help the parents rather than treating the child to help the child). M. Scott Peck, in his “People of the Lie” describes some such situations, very extreme to be sure — one example involved parents that gave their son the very same rifle, as a gift, his brother used to commit suicide.

  14. Re: Speed, You can gt in but you can’t get out.

    While I was visiting a relative in an institution for the pathologically perplexed, there was a shift change. Wanting to go home, I was unable to convince the new gate keepers that I was not an inmate.

    I tried the usual things and got nowhere – apparently they’d heard everything.

    If one of the first shift’s gatekeepers hadn’t forgotten his keys and come back and recognized me I would likely have spent the night there.

    I wonder if I would have been billed for it.

  15. I work in the health insurance field and see many breakdowns for behavioral health that can seem silly — ostensibly, all that is really needed is general categories. However, specificity can be helpful for people looking for therapists who have certain areas of expertise. My problem with the constant expansion of listed disorders is that it can trivialize truly chronic disorders and one can lose that sense of weight that real long term disorders should have: If every type of temporary upset is to be classified as a disorder of some sort, then how does that reflect on real personality disorders. Everyone suffers from a loss at some time but not everyone can understand what it is to suffer from Generalized Anxiety Disorder.

    Then there is also the risk of possible oversimplification. In the draft of DSM V they eliminate Aspergers Syndrome as a separate disorder and it is simply listed as a form of Autism. Many Aspies don’t like this because there is more to the situation that the denotation. There is the connotation. Describing oneself as Autistic is quite a bit different than saying one is an Aspie. Many connotations in the social realm can seem as unnecessary baggage to explain away. Supposedly, this change will be good for getting treatment of Aspie children as autistic. But why? Because of the weight of the label in the mind of insurers or politicians who want to manage health. The labeling becomes a political issue. Isn’t that just wonderful?

  16. I’ll throw in my two cents. Years ago, I read a book, I believe it was “Listening to Prozac. The author, a Doc, said that we diagnose mental conditions, based on having a treatment for them. He said he was treating patients with prozac, who would have been considered just eccentric ten years before. He questioned whether we would reach the point where we can ‘cure’ various personality traits and would the World be better for it. Homosexuality is a good example. It was once considered a disorder, but when no treatment was demonstrated to cure it, it became normal. As we’ve developed more drugs to use, it makes sense that we can treat things that had no treatment before. It then makes sense to define more things as a disorder.

  17. “Make them sick. Make them well” is a marketing technique which encourages the market to recognize problems for which you have a cure. That the problems so identified might not need a cure isn’t relevant. That there are real problems lacking a cure isn’t entirely relevant either.

    Attempt to cure what might be cured and ignore anything else.

    I understand that DSM assigns numbers to disorders.

    Are treatment providers required to be certified in treatment by affliction number down to the second decimal place? If not, seems like an opportunity for the certification boards to so require and while they are at it require continuing education so practitioners can sit through long training sessions given by someone with a tenth the hands-on in the subject.

    Looking at the diminishing puddle of normality from dry land is a bit disturbing. Is there a number for that?

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