Weird Stuff in the DSM-5

very so often, the question comes up again: should homosexuality be restored as a mental disorder in the APA's DSM (Diagnostic and Statistical Manual of Mental Disorders)?

Its removal due to political complaints raises three questions. First, is the DSM supposed to be a work of science or of politics? Second, just how crazy do you have to be to get the disease you suffer from listed in the DSM? And third, what is a ‘mental disorder’, anyway?

Well, as luck would have it, the DSM-5 was on sale online last week at 50% off (which probably means there's a 6 coming out soon). So I did a little investigation.

I discovered that my three favorite diseases—Alzheimer's, Parkinson's, and vascular dementia—are all listed. Traumatic brain injury is there, as are the big three from what they used to call Abnormal Psych: antisocial, borderline, and narcissistic personality disorder, and of course depression is there. Rett syndrome and frontotemporal dementia are also mentioned, and there are a couple pages on prion diseases, including CJD (mad cow disease).

Yet stroke is mentioned only in passing, and the following are not listed at all: multiple sclerosis / demyelinating disorders, Williams-Beuren syndrome, Munchausen syndrome, and leukoencephalopathies. All out. NONE of the lysosomal disorders and lipid storage diseases (Batten disease, Niemann-Pick diseases A,B,C, or D, Gaucher, Fabry), or mucopoly­saccharid­oses are listed. Mitochondrial diseases, ALS (Lou Gehrig disease, amyotrophic lateral sclerosis), epilepsy, and kuru are all missing! But tarditive dyskinesia is there. Go figure.

What is going on? Some of these are mental disorders and some are neurological diseases. It looks like a mishmash of stuff selected at random. What, if anything, are the criteria for including something in the DSM?

Here are the book sections and number of pages:

By far the biggest section is on substance abuse. Lots of disorders that may or may not be real are also in there, including Restless Leg Syndrome, Tobacco Use Disorder (6½ pages), Caffeine Use Disorder (5½ pages), Housing Problems (Homelessness, Discord with Neighbor, Lodger, or Landlord), Trichotillomania (Hair-Pulling Disorder), along with five pages on “Hoarding Disorder” and 3½ pages on Frotteuristic Disorder (a paraphilia where somebody rubs up against a stranger and somehow manages not to get slugged).

Over 90% of Americans drink caffeinated beverages daily. If classification of caffeine use in the DSM as a mental disorder creates any stigma, it's not having much effect. Many people would object to calling homelessness a mental disorder as well.

So the answer to the first question is clear: whatever this is, it's not science, and it's certainly not systematic. It's more like, if somebody comes in to a clinical psychologist and complains about something, it goes in. If they complain about it being in there, it comes out.

Which, just by coincidence, is my strategy for cooking food: if it makes noise, cook it until it stops making noise. If it doesn't make noise, cook it until it starts making noise.

With so much attention in the DSM on drug abuse and homelessness, it seems that psychiatrists are becoming social workers. Psychiatry is now a defeated battleground; their theories are gradually being abandoned and most of the remaining troops have moved on. Thomas Szasz identified the problem in his 1970 book The Manufacture of Madness. He wrote:

We systematically delude ourselves by interpreting changing fashions in scapegoating as moral and scientific progress.

Szasz pointed out striking parallels between the DSM and Malleus Maleficarum, the manual used by witch hunters in the 15th to 17th century. Most people, Szasz said, would go to elaborate lengths to avoid being accused of witchcraft, but ironically, the Church created what witchcraft there was by defining what people should believe.

That's what happened in psychiatry: its concepts are so ingrained that people identify themselves and their enemies in terms of which psychiatric disorder fits them.

The scapegoats today are drugs. The question is: is taking a drug a mental disorder? Or is it only one when you're disturbed by it? Or when your parole officer complains?

Psychologists play a useful role in helping people adjust to their life situation. Diseases like Alzheimer's are probably included because psychiatrists can give advice on how to cope with their effects. Diagnosing something you can't measure is hard enough when it's a real disease. But when something is a disease only when the patient thinks it's one, it means the definition is circular, and it calls into question its scientific validity as a disease entity.

Doctors are uncomfortable classifying any freely chosen behavior as a disease, because there's no objective way of assigning moral status. Thus, what the removal of homosexuality signifies is that the APA considers it to be a freely chosen behavior.

But the new definition of a disease is also unsatisfactory. It means that anyone can call anything they want a mental disorder, because the term becomes scientifically and medically meaningless. So the answer to the second question at the top—how crazy do you have to be to get into the DSM—is: not very. Or, in DSM-ese, the disturbance only has to cause ‘clinically significant distress or impairment in social, occupational, or other important areas of functioning’ [p. 21].

‘Clinically significant’ is an even fuzzier term. Those with neurological disorders would be much better off going to a M.D. than a psychiatrist. As for the third question—what is a mental disorder—if you have to spend one and a half pages defining the term (as they do starting on page 20), then you might as well just admit there really is no such thing.*

* (Long boring footnote, Aug 08, 2017) Szasz's view, as I understand it, or at least the part with which I agree, is that if there's no physical pathology then calling it a ‘mental disease’ or ‘disorder’ is merely a metaphor and scientifically inaccurate. So conditions like schizo­phrenia, PTSD, and depression probably qualify as disorders, but many others may not; the evidence does not allow us to decide. Where the DSM uses the word ‘disorder’, a better word might be ‘behavior syndrome.’ What I'm saying above is that calling something a disorder only if the patient or those around the patient think it's one is an unsatisfactory solution.

aug 07, 2017; last edited aug 25, 2017, 5:09 am