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Thursday, July 20, 2017

In defense of keeping LGBQT out of the DSM

The question sounds political, but it goes to the heart of what is science and what isn't

I 'm no fan of the APA. The Diagnostic and Statistical Manual (DSM-5), which it publishes, reminds me of the Malleus Maleficarum, the Hammer of Witches[1], which is to say it describes in great detail how to identify things which may or may not really exist.

Thomas Szasz pointed out the similarities[2,3]: both mental illness and demonic possession are external things that affected people and could be extirpated with appropriate incantations.

Malleus Maleficarum
Malleus Maleficarum

The Malleus Maleficarum was very popular in the late Middle Ages; it was, in its time, equivalent to the DSM in popularity and purpose. It is said that between its publication in 1486 and the appearance of Bunyan's Pilgrim's Progress in 1678, it was second only to the Bible in sales.[4] Part of the reason may be that, like its modern counterparts in Freudianism, the Malleus focused very much on sex.

Belief in witches was prevalent: no one knew who might secretly be a witch. In those days it is likely that no husband would have dared say to his wife, “Make me a sandwich!”

Well, maybe that's an unfair comparison, and you might ask: okay, Mister Smartypants, enough with the magic jokes already. If it's so unscientific then why not just include homosexuality and LBGQT?*

The reason is that homosexuality is, strictly speaking, not a disorder but a behavior. It may not be particularly safe or beneficial to society, but if clinical psychology is ever to have a scientific basis, then behaviors must be rigorously excluded. If there's a basis for them in pathology, then the pathology, and not the behavior itself, is what ought to be included.

Supporters of the DSM argue that its benefits outweigh its liabilities. Without a DSM, the probability arriving at a consistent diagnosis is significantly decreased. But there's a problem. Very little in clinical psychology today is able to answer the question “How do you know?”. This question even more fundamental to science than Karl Popper's criterion of falsifiability. Falsifiability is merely a roundabout way of emphasizing the importance of counterfactuals. It's a way of stating that the basis of science is causality.

Causality is certainly important, but it's not necessary for science. In quantum mechanics and particle physics, for example, cause and effect play little role; radioactive decay is said to be purely random, and therefore uncaused. Yet few would deny its place in science.

The defining characteristic of science is not causality, but its emphasis on repeatable empirical observation. It's why archaeology is a branch of science but history is not. An article is not admitted to the research literature unless it states explicitly how its results were measured and explains why the methods used were valid.

Thus, anyone wanting to classify a behavior as a disease must explain how they know it is a disease and not a symptom of something else. We can see this more clearly by comparing it with Parkinson's disease: its diagnosis is based on neurological examinations and confirmed only upon autopsy. But few would question its existence, because we have biochemical evidence that it is a neurological disorder.

If some behavior is to be classified as a disease, a basis in brain pathology must be demonstrated. Unfortunately, after a century of effort, despite some progress (especially on depression and schizophrenia), the disease model remains mostly a metaphor.

The DSM is an attempt to classify behavior, but it fails on two grounds. First, its classifications are largely arbitrary because they're based on observations of behavior, which are subjective.

Second, it encourages us to consider a mental state as evidence of pathology only when its effects are disturbing to the patient. If patients are happy identifying as a dehumidifier, psychologists must consider it a healthy adaptation. This creates the problem that, in those rare cases where the patient is actually not a dehumidifier, neither the patient nor the doctor is dealing with objective reality, and it pushes psychology away from science and toward its opposite: the postmodern view that reality is a social construct.

It also demonstrates the explanatory vacuum of the DSM's approach. If psychology requires a long list of behaviors and conditions—one often-quoted section says that major clinical depression exists if the person is not in a state of bereavement, unless the bereavement has lasted more than two months—then it is relying too much on arbitrary and artificial definitions that lack theoretical or empirical justification. In short, it does not answer the question how one knows and therefore it is not scientific.

Who cares? Everyone should. Psychiatrists have immense power. It might not be fashionable to perform lobotomies[5] any more (but see here), but they can still deprive a patient of freedom and prescribe powerful drugs if they decide the patient needs them. In the absence of a viable theory of the brain or a validated brain pathology, this decision, as Szasz repeatedly pointed out, risks becoming political.

Clearly something out of the ordinary is going on in the brains of some people. But until we understand how the brain works, we're probably going to be stuck with a diagnostic manual in some form or another. Meanwhile, removing the cruft, the navel lint, and the diagnoses based on social judgments of right and wrong, if nothing else, makes the DSM smaller. That's a step in the right direction.

Removing behaviors from the DSM may have been a political act, but it was not a defeat for social conservatives. Even though it legitimized and destigmatized harmful behavior, it was a victory for liberty and for science and a defeat for anyone who would like to imprison political dissidents. The DSM should not be a compendium of social mores. Classifying behavior as a form of disease may be tempting when you disapprove of it. But as the saying goes, what goes around comes around.

1. Kramer H (1486). Malleus Maleficarum, Maleficas, & earum haeresim, ut phramea potentissima conterens. (The Hammer of Witches which destroys Witches and their heresy as with a two-edged sword).

2. Szasz T (2007). Coercion As Cure: A Critical History of Psychiatry. Transaction Publishers. Review

3. Szasz T (1970), Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement. Harper.

4. Guiley, Rosemary (2008). The Encyclopedia of Witches, Witchcraft and Wicca. Checkmark Books.

5. Lobotomies are surgical disconnection of the frontotemporal lobe, which is responsible for planning. Patients are described as zombie-like, not caring about anything or anyone. Cingulotomy uses electricity, heat, or cold to destroy the white matter connections to the anterior cingulate gyrus. This brain region is behind the frontal lobe. It is part of the limbic system and is believed to be responsible for error detection, reward-based learning, pain, and regulation of emotions. The linked 2013 article says that cingulotomies are being considered for obsessive-compulsive disorder in Scotland.

created jul 20, 2017; last edited nov 16 2017, 4:35 am

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