December 15, 2008

Should Hubris Be In The DSM-V?

Certain psychiatrists carry considerable weight in determining the policy, the spirit, of psychiatry.  Henry Nasrallah is one of those men, which is why, if you see him write an editorial called, "Should psychiatry list hubris in the DSM-V?" -- especially if it is tongue-in-cheek--- you should strike yourself in the head with a brick until you are unconscious.  You are about to be manipulated with words, and then it will be too late.

He begins:

A recent book contends that psychiatry has transformed normal sadness and sorrow into a depressive disorder,(1) which would be akin to saying primary care physicians diagnose every mild cough as pneumonia. The book's premise is not true, of course, but it's a perfect example of how misunderstood serious mental illness is.

As a rhetorical point, you'll observe that his opening volley is not to refute the book, but to dismiss the book, ipse dixit.  "...not true, of course."  The authors of said book aren't some nut bloggers, and despite the premise, the book contains a forward by Robert Spitzer-- the creator of the DSM.  Perhaps "of course" is too hasty?

But dismissiveness isn't his real problem, it's his choice of analogies.  Psychiatry isn't being accused of taking ordinary symptoms of cough and exaggerating them into pneumonia-- because then it could be easily unmasked.   What psychiatry does is to call "cough" itself a major disorder. It makes this definitional, safely axiomatic, and thus irrefutable. Not, "he's much sicker than he seems," but "what he is, is sick."

Here's another rhetorical trick he uses.  He gives examples of what pathologizing human traits would look like to show how preposterous such a thing would actually be: 

How about "Verbal Diarrhea" for folks who chatter incessantly at a cocktail party or committee meeting, or "Intellectual Constipation" for our friends with exasperating narrow-mindedness. And for the painfully irritating person, "Social Hemorrhoid" might be apropos.
But this isn't jest, it's Greek Math.  He cites these examples so that other things don't seem so preposterous. "It's obviously wrong to eat babies, but under certain circumstances, adults are ok."  So while we're crapping on Verbal Diarrhea as a disorder, Internet Addiction slips in unnoticed.

But hold on: the examples aren't preposterous, they are already pathologies.  Ok, they're not disorders, but they are signs of disorders.  Don't be fooled by the aliases.  What Nasrallah doesn't realize (?) is that these "symptoms" signify, connote, a disorder, a process that cannot be undone.  "He has mood swings" means he has bipolar, even if he doesn't.  Even if 100 psychiatrists later agree he doesn't have bipolar, the diagnosis stays open: every aspect of his life will be forever measured against bipolar. 

If the cough is a symptom of "Cough Disorder"-- who can protest?

Let's not forget those who throw temper tantrums when they can't have their way: they may suffer from "Temperamental [sic] [sic] Arrhythmia."
Note my double [sic], his example is wrong all over the place.   If it's temper tantrums he's worried about, then the disorder is more properly "Temper Arrhythmia,"  which already exists: we call it Oppositional Defiant Disorder.

But if he meant a disorder of temperament-- which everyone pronounces "temperment" and so could be confused with meaning "temper"-- then that's  a disorder, too, because  temperament means innate personality traits: he's having temper tantrums because he is genetically predisposed to having them.

One thing psychiatrists love to do, myself included, is comment on social policy.  He couldn't leave this one alone:

Take the worldwide financial meltdown triggered by questionable practices of banking executives who thought they would never fail or be caught on their way to accumulating obscene wealth. They certainly left a lot of wreckage in their wake, so perhaps psychiatry should create new diagnostic entities of "Horrendous Hubris" and "Gargantuan Greed."
He doesn't cite the greed of a generation of people who overleveraged,  who didn't save for their own retirement or their kid's college or anything else-- I'm not talking about the poor, I'm talking about everyone who made TVs, DVDs, cars, boots that cost $200 but show up on the credit card statement as "$15/month"--made it so that stuff isn't considered luxury items.

No, he chooses the greedy bankers.  On the surface, it seems he's using this as an example of something psychiatry could easily pathologize, but doesn't-- ergo psychiatry is rigorous.  But that's all a ruse.  He picks this as an example of hubris not being a disorder so that he can label the bankers as greedy.  That's the purpose of this example.  Someone else's greed-- say, a gambler's, or someone who does not offend him-- that could be pathology, that could be bipolar.  So what he's showing you here is not the framework of normal vs. pathology, but how he gets to choose what to pathologize, and when.

My point is that the social retina of psychiatry does not perceive ordinary human traits and emotions such as normal sadness as pathologic behavior. But psychiatrists certainly are willing to intervene when people seek help on their own for problems such as depressive episodes that are disrupting their lives or are referred by physicians or brought in by family or friends who recognize the potential gravity of their afflictions.
Words are always and forever beautiful lies, the enemies of logic, when you hear them you should run away, seal your ears with wax or drown them out with a lyre's song, lest you be seduced to your death;  they don't tempt your body, they tempt your spirit, and no one can resist them. 

On the one hand psychiatry doesn't see normal sadness as pathology; on the other hand, psychiatry will intervene when someone else sees pathology.  So when, ultimately, does normal sadness constitute a disorder?  When someone says it does, that's when.  Ipse dixit. 


So... when is something REA... (Below threshold)

December 15, 2008 4:54 PM | Posted by Diego: | Reply

So... when is something REALLY pathological? Biological health problems could easily be diagnosed 500 years ago as they can right now ("Your arm is missing", "Why are you coughing blood?"), however, mental health is a bit blurrier.

If you're sad, when does it become a disorder? When is it abnormal? When it disrupts your life? Because you can let anything disrupt it. Before kids where kids, now they have severe issues that must be dealt with.

I'd like a real opinion about that, a true study about what is and what's not.

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My own take on the meaning ... (Below threshold)

December 15, 2008 6:13 PM | Posted by Fargo: | Reply

My own take on the meaning of pathological is when the person either is denied the choice to do/not do something, or that choice is heavily leveraged one way or the other. Be it brain chemistry or conditioning. Normally, we can really exert influence over something we do. Like whether to have a pleasant conversation with someone or hit them about the face. A person with an actual problem would either find it impossible to do one of those, or would have to expend a tremendous amount of focus on doing one over the other.

Similar to, say, damage to the nerves of your hand. Most people can hold a glass with almost zero overhead in focus, but this damage means you have to really focus on it, to the point that your capacity to focus on other things is noticeably impaired.

I could be wrong, I'm just a nut reading a wacko's blog, but that's the general impression I have.

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"...a true study about what... (Below threshold)

December 15, 2008 7:42 PM | Posted, in reply to Diego's comment, by Anonymous: | Reply

"...a true study about what is and what's not."

He just told you--it is whatever Nasrallah (or whomever has authority) says it is. There can be be no "true study"--there can only be a count of raised hands in a room.

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One day, when I grow up I h... (Below threshold)

December 15, 2008 8:48 PM | Posted by Lexi: | Reply

One day, when I grow up I hope I'm as quick as you are-- and I mean that in the genuine sense. You have the admirable ability to parse things and see through the manipulation, and I really appreciate you walking people through this sort of thing step by step. I may have caught on later in the article about the time he talks about bankers as being the only ones at fault . . . but by then I may have already accepted too much of his argument as well. Who knows. Anyway, when I read stuff like what you write, it models for me how to parse things in a way that may be more helpful for consuming information without buying into it. So thanks, dude.

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"...connote, a disorder, a ... (Below threshold)

December 16, 2008 12:18 AM | Posted by Anonymous: | Reply

"...connote, a disorder, a process that cannot be undone. "He has mood swings" means he has bipolar, even if he doesn't..."

Thank you.

I have been trying to figure out what is so off putting about therapy for 2 years. I was always concentrating on the judgment of the therapist, you are intimidating people. Scary to talk to.
Attacking, or avoiding the person chosen to help leads others to assume you don't want to change for the better.

Pointing out what is wrong in the methodology is a perfect thing because that can change. Always.

I hereby vote that there are no disorders until the doctors have created a finite definition of normalcy. (never in a free world) How about we call em...personality dilemmas?
So then people will think of choices and how difficult there are, but the fact that there are still solutions.

Psychologists and psychiatrists decrying what is right and wrong and hiding in vagueness only your little pills, pills you don't even fully understand, can solve. When I asked for an explanation of citralopram I was told about seritonin and chemicals and molecules, that theses were all reasonable assumptions. When I asked about long term studies I was told that "oh you ask such good questions, so are so smart." over and over again, until I figured to stop asking. It's depressing after awhile. No. wait. It's not depressing, citralopram is awesome!

Stay away from drugs kids! Unless prescribed.


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“We will be restor... (Below threshold)

December 16, 2008 8:11 AM | Posted by Aaron Davies: | Reply

“We will be restoring normality just as soon as we are sure of what is normal anyway.


“We have normality, I repeat we have normality. Anything you still can’t cope with is therefore your own problem.”
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Nice find. fyi... a similar... (Below threshold)

December 16, 2008 10:34 AM | Posted by Anonymous: | Reply

Nice find. fyi... a similar argument was made in this paper.

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I think it should be. Being... (Below threshold)

December 16, 2008 1:51 PM | Posted by Cada: | Reply

I think it should be. Being a Self Injury myself, that is a total new way of injurying yourself. Does one not know what objects inside can cause effects inside the body. It should be thats all I have to say. I don't cut (anymore) nor would I insert things in my body or skin (unless maybe if it was like a saftey pin and it was only going to be like a peircing of the flesh...but thats another matter)

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"Personality Dilemma" -- AW... (Below threshold)

December 16, 2008 7:03 PM | Posted, in reply to Anonymous's comment, by xon: | Reply

"Personality Dilemma" -- AWESOME!!! Seriously excellent and insightful observation. The simple semantic would do more to revolutionize psychology and psychiatry than Freud, Jung, and Ritalin combined.

Too bad my vote doesn't count.

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I think that those who doub... (Below threshold)

December 17, 2008 3:12 AM | Posted by Anonymous: | Reply

I think that those who doubt the reality of sub-institutionalization mental illness probably don't have it. There's this certain mindset which exists, on one hand will validate crazy exists (to deny crazy is to be as irrational as a scientologist). However, on the other hand only validate crazy as being in a state so desolate and destroyed that one is a chattering lunatic in a nut home (or, at one time, was in such a state).

Not all coughing is pneumonia, but most of the time coughing is a good indication you're sick and need some sort of treatment. Just because cough doesn't always equate to pneumonia doesn't mean that lack of pneumonia equals normality and health.

People who fuss about the changing definitions of depression and bipolar are being anal, missing the point. When manic depression was renamed bipolar disorder, this took the emphasis off of the psychotic requisite of the condition and instead placed the emphasis on the fact that moods and energy fluctuate dramatically. To be manic is to be psychotic, but to be bipolar is simply to have disregulated brain energy.
When this was done, people with problems that did not involve psychosis but DID involve disregulated brain energy now had a name. Thus, the bipolar spectrum was invented.

Many of these conditions may not be etiologically related to manic depression. So what? Type 1 diabetes has no commonality with type 2 diabetes, pathologically speaking. Even the nature of hyperglycemia is different (type 2s will have much, much higher blood sugars whereas type 1s can be near death at a level of glycemia that a type 2 would not be in such a dire health state). Type 1s will have much more severe complications than type 2s, because the nature of their glucose regulation is so much more seriously deficient, thus life threatening (a complete lack of insulin).

In spite of these differences no one whines about the unrelated nature of type 1 and type 2 diabetes... the symtpoms are somewhat similar, so they are considered different types of the same disease.

Why do people have such a problem with the evolution of how we conceptualize psychiatric illnesses?

Is it about control, I wonder? Do we reject the notion of mental illness, unless the person being labeled with mental illness is too incapacitated, too disoriented, too unconscious? Because, unless it's obvious the brain is decimated, it must be normal personality stuff that we need to get over?

If I can't control you, you aren't sick.
If I can't control you, you can control yourself.
If I can't control you, you can threaten me.
What you feel or think is irrelevant and does not define illness. I define illness. Illness is defined by control.

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Isn't it kind of old-fashio... (Below threshold)

December 17, 2008 1:32 PM | Posted by Jason: | Reply

Isn't it kind of old-fashioned to frame what goes on in psychotherapy as a health/disease issue?

Isn't that illness/doctor model a vestige of earlier prejudices against psychology in general?

I think this wider point is more important than this debate over what "is" and "isn't" sick or healthy.

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Isn't it kind of o... (Below threshold)

December 17, 2008 6:02 PM | Posted, in reply to Jason's comment, by Siderea: | Reply

Isn't it kind of old-fashioned to frame what goes on in psychotherapy as a health/disease issue?

Isn't that illness/doctor model a vestige of earlier prejudices against psychology in general?

Well, that depends on what you mean by "old". It came in in a big way around 1974, when the aforementioned Robert Spitzer, who may have done more thinking about what does and does not constitute mental illness than anybody else in a position to do something about it, was named to chair the Task Force on Nomenclature and Statistics, formed to produce the DSM-III. He was a "Young Turk" (as they called themselves) who advanced the "medical model" over the "biopsychosocial model" (to use Wilson's terms) of the neo-Freudians. Spitzer populated the the DSM-III Task Force with fellow "neo-Kraepelinians" so that the DSM-III, unlike the previous two DSMs, would be based on the medical model and thus pushed firmly into the tradition of scientific logical positivism. Or, well, that was the idea.

Spitzer and his fellow Young Turks succeeded. The histories of psychiatry largely refer to what he and his fellows pulled off, in reforming american Psychiatry by reforming the DSM, as a "palace coup" or "revolution". Today, the Freudian model is completely marginalized (as well it might be!) and largely irrelevant. The medical model has ideological hegemony in the mental health professions.

I don't think you're at all wrong to situate the fundamental problem with trying to impose a medical paradigm onto what it is that psychotherapy engages with. But the people who define these things are doctors and, having deeply invested in advanced graduate study in hammer-wielding, aren't likely to stop treating everything as a nosological nail.

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Citalaphram (Celexa) saved ... (Below threshold)

December 18, 2008 1:54 PM | Posted by AK: | Reply

Citalaphram (Celexa) saved my ass.

I was in misery, irritable, getting into fights, and this was a radical change in my usual behavior. I was exercising taking omega 3s, eating an excellent diet, doing therapy and trying to apply Cognitive Behavioral Therapy.

I was unable to gain traction.

Two hours after taking my first Celexa tab, I settled down, was lucid and felt like Id gone from a pair of broken down shoes to a set of Italian custom mades.

And no, I do not work for Big Pharma.

I tried all I could to avoid meds, but when I did finally get the right one, I could finally benefit from CBT.

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The entire body of thought ... (Below threshold)

June 8, 2010 8:46 PM | Posted by Matt: | Reply

The entire body of thought that is now known as "psychology" will eventually be divided between four disciplines:
1. Neurology
2. Endocrinology
3. Religion
4. Voodoo

The former two are the proper province of doctors. The third should be left to priests. And the fourth should be discarded entirely. But at present there's an awful lot of religion and a truly mind-numbing amount of voodoo being dragged into the practice of psychology and handed white lab coats.

People want pills. Before physicians are allowed to give them any pills, they have to diagnose them with a disease. And so a lot of people are being handed diagnoses of diseases that they either don't actually have, or that aren't even proper diseases to begin with, just because nobody's satisfied unless the meeting ends with pills.

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This sounds very similar to... (Below threshold)

January 7, 2015 5:39 PM | Posted by Anonymous: | Reply

This sounds very similar to a rebuttal of an evolutionist paper, wherein the refrain, "Everyone says that evolution is wrong just because it's a "theory," but what about [gravity/photosynthesis]. . . ."

Different topic, same dancing about an issue on feet made light with long years of practice and a strong enough bias.

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