Posts Tagged DSM
Sexual Disorders Are Not Illnesses
Posted by Phil in A Behavioral Approach to Mental Disorders on June 28th, 2010
The central theme of this blog is that almost all the so-called mental illnesses listed in the APA’s Diagnostic and Statistical Manual are nothing more than the ordinary everyday challenges of human existence. The psychiatric profession has “elevated” these problems to the status of disorders and illnesses to justify and legitimize their involvement in these areas, and in particular to justify the use of drugs to alter people’s moods and actions. Psychiatry – once a respectable helping profession – has degenerated into something little better than drug pushing. The real winners, of course, are the pharmaceutical companies, who use the psychiatrists and other mental health professionals to promote the widespread drugging of the population. The DSM’s so-called sexual disorders represent a particularly blatant example of psychiatric invention.
Imagine the case of an attractive well-dressed young land who boards a crowded bus or train. It’s standing room only, and after a few minutes she becomes aware of the fact that the gentleman standing behind her is pressing his groin against her buttocks. At first she thinks that it is just because the train is crowded. So she inches away from him, but he follows and the pressing continues. She becomes angry. She may confront him, but often does not for fear of causing a scene. Frequently she just exits at the next stop, seething with anger and a sense of helplessness. Perhaps later she recounts the incident to her husband, boyfriend, co-worker, etc… Her response to the incident remains one of anger, but this usually dissipates in time as she writes the perpetrator off as a “dirty little pervert” or some such.
What she doesn’t’ realize, however, is that the perpetrator is in reality “suffering from” a “mental illness” called frotteurism. This is an “official” DSM diagnosis. Let me quote:
The paraphilic focus of frotteurism involves touching and rubbing against a nonconsenting person. The behavior usually occurs in crowded places from which the individual can more easily escape arrest (e.g., on busy sidewalks or in public transportation vehicles). He rubs his genitals against the victim’s thighs and buttocks or fondles her genitalia or breasts with his hands. (DSM IV TR, p 570)
I am not making this up. Over the years, the APA has learned that they can get away with almost anything, and the diagnostic categories expand and expand and expand. And the psychiatrists’ and pharmaceutical companies’ cash registers go kerchung, kerchung, kerchung.
As far as the psychiatrists are concerned, every human problem is a mental illness and should be “treated” with drugs.
Next post: More on the so-called sexual disorders.
Personality Disorders Are Not Illnesses
Posted by Phil in A Behavioral Approach to Mental Disorders on May 5th, 2010
The central theme of this blog is that there are no mental illnesses. The concept of mental illness is a spurious invention of psychiatrists and other mental health professionals for the purpose of medicalizing normal human problems and selling drugs.
The central tenet of the mental health system is that unusual, bizarre, and disturbing behaviors are caused by mental disorders (or illnesses). But their definition of a mental disorder is: a serious behavioral problem. So problem behavior is caused by problem behavior. This is the facile logic behind the widespread peddling of drugs in which psychiatry and the mental health system engage.
Within the mental health system a personality disorder is conceptualized as a specific kind of mental illness and is defined as follows:
“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” (DSM-IV-TR, p. 685)
DSM lists eleven different kinds of personality disorder. These are: paranoid; schizoid; schizotypal; antisocial; borderline; histrionic; narcissistic; avoidant; dependent; obsessive-compulsive; and of course, personality disorder not otherwise specified.
Let us examine schizoid personality disorder. The APA lists the following criteria:
A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:
(1) neither desires nor enjoys close relationships, including being part of a family
(2) almost always chooses solitary activities
(3) has little if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or confidants other than first-degree relatives
(6) appears indifferent to the praise or criticism of others
(7) shows emotional coldness, detachment, or flattened affectivity
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder
With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental
Disorder and is not due to the direct physiological effects of a general medical
condition. (DSM-IV-TR, p 697)
It is clear from even a cursory examination of these criteria that what’s involved here are the qualities of solitariness, introspection, and stoicism. Note in particular that the criteria do not require that the individual be troubled by these qualities. Even if a person is perfectly contented with his habitual state of quiet isolation, he nevertheless has a mental illness and swells the ranks of the “untreated sufferers.” The so-called schizoid personality disorder is one of the more blatant examples of the APA’s pathologizing of normal human differences. Even their selection of the word “schizoid” serves to impart connotations of danger and hidden pathology.
The fact is that each of the criterion qualities listed above is present in the human population to a varied degree. And it is indeed the case that some individuals are introspective and isolative to an extreme degree. Assuming, however, that this necessarily constitutes a problem is unwarranted and dangerous. Most of the introspective individuals I have known are contented productive people who would be truly appalled to learn that in reality they are suffering from a mental illness and that they need treatment (i.e. drugs). The drugs, of course, will be prescribed by a psychiatrist and manufactured by a pharmaceutical company. It is little wonder that a former surgeon general could state that one fifth of the US population is suffering from a mental disorder in any given year. As has been stressed many times in this blog, the primary purpose of DSM is not to advance our knowledge of ourselves as a species, or help us become more resilient and adaptive, but rather to generate income for psychiatrists and pharmaceutical companies.
The reader who is not particularly isolative or introspective might be thinking “Oh, well – but it doesn’t apply to me.” Read on.
Here are the DSM criteria for dependent personality disorder:
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
(2) needs others to assume responsibility for most major areas of his or her life
(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.
(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
(7) urgently seeks another relationship as a source of care and support when a close relationship ends
(8) is unrealistically preoccupied with fears of being left to take care of himself or herself
Two generations ago probably half the women in our culture would have met these criteria. (Note that only five of the items have to be met.) Even today a substantial percentage of the women in our society are raised to think of themselves as essentially dependent and as having little or no personal identity until they have become “hitched” to a man. By calling this a mental disorder, the APA is pathologizing what for many individuals is a normal state. It is also critical to note that the only reason that this particular lifestyle is a mental disorder is that the APA say so. The APA attempts to promote the idea that their so-called diagnoses are based on science. This is simply not the case, and is certainly not true of the so-called personality disorders. The APA and its various committees have simply decided that certain lifestyles and mindsets are to be considered pathological. They pretend that this reflects some kind of reality, i.e. that in fact these individuals are truly damaged in some way. But in fact the determination that certain mindsets constitute disorders while others do not is entirely arbitrary.
Why, for instance, is there not an independent personality disorder? After all, if people who are extremely dependent are to be considered pathologized, why not the individuals at the other end of the continuum? Individuals who never ask for help; who conceptualize asking for help as shameful; who are driven to succeed by their own efforts; who never see themselves as part of a team, etc., etc.. One could easily draft eight or ten criteria, arbitrarily require that 3 or 4 or 5 of these be met, and voila! A new diagnosis. Frighteningly, there are probably individuals within the APA who would take this suggestion seriously. The APA’s objective is to pathologize as much normal behavior as possible, and this has been demonstrated clearly by each successive revision of the DSM.
Next Post: Sexual Disorders Are Not Illnesses
The So-Called Mental Illnesses Are Not Illnesses
Posted by Phil in A Behavioral Approach to Mental Disorders on April 15th, 2010
The central theme of this blog is that mental illness is a spurious and invalid concept, which is promoted and developed by the American Psychiatric Association to legitimize the use of mood-altering drugs.
It is certainly true that people display various problems in their daily lives and particularly in their interpersonal relationships. The American Psychiatric Association claims that all such problems are caused by mental illness and their list of these so-called illnesses is so long that virtually anybody can be embraced within their coils.
It is also true that problem behavior can be the direct result of an illness. The paradigm example of this is general paresis. This illness, which is in fact an advanced stage of syphilis, often generates psychotic symptoms and at one time accounted for 10-20% of mental hospital admissions. But psychotic behavior and other behavioral problems can and do occur in the absence of any underlying illness. Indeed it is my main task in these posts to show how these kinds of behaviors can be explained in terms of the ordinary constraints of daily living.
The vast majority of mental health workers subscribe to the APA’s philosophy. There have been voices of dissent, however. The late George Albee, PhD, wrote this in 1999:
“Most mental/emotional problems are learned patterns of maladaptive behavior resulting from the stresses of poverty, anxiety, exploitation and abuse or neglect!” (Sarasota Herald-Tribune June 27, 1999)
William Glasser, MD, a renowned psychiatrist, was the top speaker at the 2006 national conference of the American Psychotherapy Association. The National Psychologist (Nov-Dec 2006) quotes him as follows:
“I’ve never identified anyone as having a DSM disorder. …All of these are phony diagnostic categories. The DSM was not written to help people; it was developed to help psychiatrists – to help them make money.”
The point is this: mental illness is an explanatory concept. It purports to explain unusual, aberrant, or troublesome behavior. So that if a person were to ask: Why does my mother say these crazy things? Why doesn’t she take care of herself and let us help her?” The answer from the mental health establishment is: ”Because she has a mental illness called schizophrenia.” We’ve discussed the circular nature of this so-called explanation in an earlier post. And the fact is that it’s not an explanation at all. It’s a soothing form of words – a mantra, if you will – that legitimizes medical involvement in the “treatment” of people who are experiencing problems with living. The history of medical involvement in these kinds of problems is not edifying, and the present-day exploitation of these individuals by pharmaceutical and medical drug pushers is no exception.
Three books I’ve come across recently on these topics are well worth the read:
| Shyness: How Normal Behavior Became a Sickness |
 Christopher Lane, PhD, Yale University Press, 2007 |
| Mad In America |
 Robert Whitaker, Perseus Publishing, 2002 |
| The Myth of the Chemical Cure (Revised Edition) |
 Joanna Moncrieff, MD, palgrave macmillan, 2008 |
Next Post: More on Personality Disorders
Conduct Disorder and Oppositional Defiant Disorder
Posted by Phil in A Behavioral Approach to Mental Disorders on April 17th, 2009
CONDUCT DISORDER
The essential feature of Conduct Disorder, according to the APA, is a “repetitive and persistent pattern” of rule breaking or activity which violates other people’s basic rights. The manual identifies four broad categories of behavior under this heading: aggression; destruction of property; theft or deceitfulness; and serious violation of rules.
DSM goes on to state that individuals with this disorder display little concern for the feelings or welfare of others, are frequently callous and indifferent to other people’s pain and loss, and show little in the way of feelings of guilt or remorse. Poor frustration tolerance, irritability, temper tantrums, and recklessness are cited as frequently associated features.
Diagnostic Criteria for Conduct Disorder
The notion that the kinds of serious misbehaviors described above are caused by a mental disorder represents an enormous departure from common sense and conventional wisdom. For this reason, the complete list of DSM criteria are set out below, to enable the reader to clearly assess the APA’s position on this matter. The manual lists the following fifteen items, three of which must have been present in the previous twelve months:
Aggression to people and animals:
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious damage
(9) has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else’s house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years
(14) has run away from home at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
(DSM-IV, 90)
It is clear from these criteria that what is being described here is plain old-fashioned criminality. A serial rapist, for instance, who threatens his victims with a weapon meets criteria 1, 3, and 7, and is therefore suffering from a mental illness. A person who smashes car windows to steal from the glove compartment, who steals from stores, and who bullies and intimidates his family meets criteria 1, 11, and 12, and is also suffering from a mental illness. Just about any kind of criminality you care to imagine is covered by these criteria. In other words, a “diagnosis” of Conduct Disorder means habitual criminality. The APA is not saying that some habitual criminals have a mental illness. Rather, they are saying that habitual criminality in and of itself constitutes a mental illness.
Prevalence
APA’s estimates of prevalence rates are high: 6 to 16% for males, and 2 to 9% for females. DSM goes on to state that Conduct Disorder is “one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children.” The so-called disorder is not confined to children, however, and the manual makes it clear that the diagnosis can be assigned to adults if they meet the criteria.
Former Times
As with most mental health diagnoses, the critical issue is not whether the misbehaviors in question represent serious problems. Clearly they do. Rather, the issue is whether or not they should be conceptualized as mental disorders. Former generations would have used more conventional terms, such as delinquency, villainy, vandalism, crime, brutality, etc., to describe these kinds of activities, and as with ADHD, would for the most part have identified lax or inconsistent parental discipline as the proximate cause. By calling these misbehaviors a mental disorder, the APA is promoting an entirely different way of conceptualizing these problems, and in particular is promoting the notion that these kinds of problems need to be treated by psychiatrists and other mental health workers. The assignment of the diagnosis also implies that the problem is something inherent to the child, and downplays the role of the parents, or indeed of other factors.
The high prevalence rates cited earlier make it clear that the individuals diagnosed with Conduct Disorder represent a sizable proportion of the government statistics mentioned in an earlier post. It is tempting to wonder if politicians and other interested parties who endorse these statistics realize that many of the “afflicted” individuals whose cause they champion are included purely on the basis of a persistent pattern of serious misbehavior and delinquency.
One noteworthy feature of Conduct Disorder is that it has not garnered as much public acceptance as ADHD, even though conceptually there are multiple parallels. The likely reason for this is a recognition on the part of the APA that ascribing such serious misbehavior to a mental disorder would not be palatable to the general public, and that a more lengthy “softening-up” period may be necessary before such a concept would be widely accepted.
OPPOSITIONAL DEFIANT DISORDER
DSM-IV-TR defines Oppositional Defiant Disorder as a “recurrent pattern of negativistic, defiant, disobedient and hostile behavior towards authority figures…” (100), characterized by temper tantrums, arguing with parents and other adults, defiance, refusal to comply with requests and directives, deliberately annoying other people, blaming others for his/her own errors, and being spiteful and vindictive.
The manual lists eight specific criteria, four of which must be present for the diagnosis to be assigned. The eight criteria items are listed below:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults’ requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful and vindictive.
There is little to be said about this so-called mental disorder that has not already been addressed with regards to ADHD and Conduct Disorder. The fundamental question is why this kind of misbehavior, which former generations would have characterized as “being a spoiled brat” should now be considered a mental disorder.
And as with the other so-called mental disorders, the answer is because the APA say so. This is in marked contrast with general medicine, where the identification of a disease usually represents an enormous breakthrough in terms of understanding and treatment. The idea of conventional medical researchers sitting in committees and inventing illnesses by voting and consensus would be considered laughable. Yet that is exactly what the APA has been doing for the past half century with successive revisions of the DSM.
As with other so-called disorders discussed earlier, the diagnosis clearly implies that the problem is something inherent in the child. This effectively lets the parents off the hook, reduces expectations, and in practice encourages a kind of self-centered egotism on the part of the child which usually persists into adulthood. The “disorder” also serves as a portal diagnosis, and typically other mental disorders (e.g., depression, ADHD) are “uncovered” as the child receives “treatment”.
In this context it is worth noting a major weakness of the entire DSM system i.e. the “all or nothing” nature of the so-called diagnoses. In conventional medicine, the all or nothing framework is generally valid. You’ve either got meningitis or you haven’t. There are, of course, degrees to which the infection may have developed, but even a mild case of meningitis is a serious condition, and a dichotomous approach is warranted – not only for treatment/administrative reasons, but also because it accurately reflects the objective reality.
The behaviors outlined above, however, as diagnostic of Oppositional Defiant Disorder are emphatically not dichotomous. Each item very clearly admits of degrees. Consider the first item on the list: “often loses temper”. This could mean anything from a few irate foot-stampings, to wholesale mayhem. Additionally, the word “often” is subject to quantification. Does often mean daily? weekly? monthly? Similar considerations apply to the other items on the list, and to the APA’s requirement of four or more items to make a diagnosis. Why not three, or five?
The fact is that childhood defiance is not a simple unified construct, and is emphatically not dichotomous. It contains multiple components, each of which admits of degrees and could be quantified. In their drive to “medicalize” all human problems, the APA shoehorned this phenomenon into a simplistic yes or no format to facilitate the process of “diagnosis.” The result is not a genuine understanding of the child’s/family’s problem, but a travesty that serves only the interests of the psychiatrists and the pharmaceutical companies. The same criticism can be leveled at almost all the so-called diagnoses in DSM.
Next Post: Anxiety Disorders
How Can They Just Invent Illnesses?
Posted by Phil in A Behavioral Approach to Mental Disorders on March 25th, 2009
The notion of a professional group such as the APA sitting in their councils and committees inventing illnesses for themselves to treat seems so preposterous that a measure of disbelief on the part of the reader is understandable. In its historical context, however, the development is not so surprising. The original 1952 DSM was very simple and unpretentious, and whilst part of the APA’s motivation in drafting the document was undoubtedly to draw some credibility and respectability to their profession, there is at the same time nothing to suggest any great drive at that time towards aggrandizement or service expansion. However, having agreed in 1952 that neurosis was a form of mental disorder, it was inevitable that subsequent revisions of the manual would attempt to define this feature further and look for subdivisions of the general category. This, of course, is exactly what has happened, and the current version of DSM lists literally dozens of disorders of this sort, although the general term neurosis is no longer used. (For an interesting discussion of this matter, see Karen Franklin’s post at In The News.)
Trichotillomania is a case in point. DSM-IV describes trichotillomania as a mental disorder in which the victim, usually a female child, twists, tangles, and pulls out her hair in a compulsive, habitual manner.
The reality is that children play with their hair, and children also frequently develop dysfunctional and counterproductive habits, such as picking their noses, putting their fingers in their mouths, etc.. It is likely that children have displayed hair-tangling and hair-pulling tendencies since before people lived in caves. Parents from generation to generation have dealt with these kinds of problems as a matter of course, as an integral part of the normal parental responsibilities.
Functional, effective parents intuitively use the normal systems of coaching, teaching, rewards, punishments, etc., in a more or less systematic attempt to instill productive habits in their children and eliminate dysfunctional ones. This includes hair-pulling. Certainly up till a generation or so ago, no parents would have conceptualized this as anything other than a habit, and the matter would have been resolved promptly within the family using natural methods of coaching, encouraging, etc..
Today, however, thanks to the widespread “consciousness raising” of the APA and the pharmaceutical companies, a growing number of parents have accepted the notion that a child displaying this kind of behavior has a mental disorder and needs immediate professional attention. Newspaper ads and free screenings, both paid for by pharmaceutical companies, promote these ideas and frequently suggest that failure to seek prompt treatment may result in matters becoming a good deal worse.
The treatment usually involves a psychotropic prescription, the side effects of which frequently are far more destructive to the child’s health than the original problem. The child is also “enrolled” in the ranks of the mentally disordered, and is given the false notion that it is impossible to deal with life’s normal problems without the assistance of professionals and pills. He or she is well on the road to customer-for-life status, which of course benefits the practitioners and the pharmaceutical companies.
In this context it is important to note that the question “is trichotillomania a mental disorder or not?” becomes meaningless, because there is no definition of a mental disorder other than the one the APA provides. If the APA says something is a mental disorder, then it is, otherwise it is not. There is no external reality to which their findings must conform. By contrast, a geologist, for instance, who asserted that wood is a form of rock would be rebutted on the grounds that wood simply does not have the objective qualities and characteristics of rock, and no amount of discussion or consensus can alter that reality. A psychiatrist, on the other hand, who suggests that road rage, for instance, is a mental disorder, merely has to persuade enough of his colleagues that this is the case, and it will become so by being included in the next edition of DSM. It is the psychiatrists who decide what is a mental disorder, and their general philosophy in this regard for the past fifty years has been “the more the merrier.” A recent editorial in the American Journal of Psychiatry, for instance, asserts that Internet addiction is a mental disorder and should be included in the next edition of DSM.
In general, business has been good for psychiatrists in recent decades. Clients are indeed seeking their help for an increasingly wide range of problems, and it is likely that DSM-V, when it emerges, will list even more mental disorders than the current edition.
Calling a problem a mental disorder obviously does not change the nature of the problem, nor does it provide any special insight into the matter. The fact is that most children play with their hair. For a very small number the habit becomes strong, and they actually tear hair out in significant quantities. When psychiatrists say, “This is a mental disorder,” essentially what they are saying to the parent is, “You can’t take care of this. You must bring this child in for treatment.” The disempowering aspect of the message is not usually articulated, but parents who succumb to these kinds of pressures do in fact become disempowered and ineffective, and usually relegate an increasing measure of their parental responsibilities to the professionals. This, of course, is good for business, but the results in terms of the child’s general development are often far from satisfactory. Furthermore, by defining the problem as something inherent to the child, the system is ignoring the role the parents may have played in the creation and maintenance of the problem, and in general, little or no attempt is made to empower or coach them towards more effective parenting. (For an interesting perspective on this, see codeblog’s post about a day in the children’s psych ward.)
In the context of diagnostic proliferation, it needs to be recognized that psychiatry is a profession, and that the APA’s primary agenda – rhetoric notwithstanding – is to promote the welfare and interests of their members. That’s why the individual psychiatrists join and pay their dues (currently $540 a year). Like other professional groups, they window-dress their documents and their press releases with public welfare platitudes, but also like other professional groups, they protect their own interests and fight tenaciously for their turf.
It should also be acknowledged that in the turf protection area, psychiatrists have enjoyed a great deal of success and have become extraordinarily adept at lobbying legislators and other decision-making bodies in matters that affect psychiatry’s financial interests. In this regard they have had the wholehearted assistance of the pharmaceutical companies, who have used their formidable advertising and lobbying power to full advantage in the drive to develop the mental disorder framework and to promote its acceptance by the American people. Pharmaceutical companies routinely fund most of the “free screenings” for depression and other so-called mental disorders that one sees advertised in the newspapers and on TV. Their funding sources are seldom acknowledged in the ads, but can usually be verified by calling the 800 number and asking where the funding comes from. In addition the pharmaceutical companies donate large quantities of money to organizations sympathetic to their cause, for instance, the National Alliance for the Mentally Ill (NAMI), and have in recent years begun targeting ads for psychotropic drugs directly towards potential patients.
The central theme of this website is that the APA’s framework, in which an increasingly wide number of human problems are conceptualized as mental illnesses and best treated by psychotropic drugs, is spurious and counterproductive. It is a disempowering philosophy that undermines not only the value and integrity of the individual affected, but also saps the strength, vitality, and creativity of our families and communities. In the following posts I will discuss some of these so-called diagnoses in more detail.
Next post: Attention Deficit and Disruptive Behavior Disorders
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