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.