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Everyone on the Couch

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Everyone on the Couch

Today’s psychiatry undermines self-reliance and morality. Autumn 2013
The Social Order
Overdiagnosis blurs the line between unhappiness and mental illness. A patient having a violent seizure in 1878.
Overdiagnosis blurs the line between unhappiness and mental illness. A patient having a violent seizure in 1878.

Allen Frances, the psychiatrist who edited the fourth edition (1994) of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (commonly known as the DSM-IV), once tried to insinuate a new diagnosis—masochistic personality disorder—into the third edition (1980). Frances, a vocal critic of the new DSM-5, released this year, now believes that no such condition exists and is glad that he failed—though he failed for reasons other than the manual’s scientific integrity.

Masochistic personality disorder, as Frances then conceived it, “diagnosed” those whose typical behavior brought them unhappiness, principally by “self-sacrifice in the service of maintaining relationships or self-esteem.” He was thinking of—or many took him to be thinking of—women who put up with violently abusive lovers or husbands, or repeatedly chose such men as sexual partners, despite previous bad experience. Feminists attacked the proposed diagnosis, arguing that it blamed women for their own abuse. And it was on those grounds, not scientific ones, that the 1980 DSM excluded the diagnosis.

In fact, the pattern of behavior that Frances’s disorder sought to categorize is common—I encountered it often in my clinical practice. “His eyes suddenly go funny,” a patient would say of a violent boyfriend, “like he’s having a fit. He stares, he doesn’t blink, and then he starts to strangle me. I don’t think he knows what he’s doing.” “Would he do it in front of me, then?,” I would ask, and the scales would fall, at least temporarily, from her eyes. But the willingness to excuse abusive behavior was often astonishing. I recall one patient with an arm and a jaw broken by a man just out of prison after a long sentence for killing another woman. She rejected our warning that she was in imminent danger and walked out of the hospital arm in arm with her abuser, proclaiming her love for him. And, in fact, no convicted serial killer fails to receive written declarations of love and offers of immediate marriage from women outside the prison walls.

Frances was right, then, to reject his 1980 diagnosis—not because masochistic behavior is a fiction but because a description of behavior is not the same as a medical diagnosis. We all show patterns of behavior, and some prove far from conducive to our own success or happiness. Such behavior does not make us ill, however, but weak and fallible.

No edition of the DSM, including the latest, recognizes a masochistic personality disorder. Yet the DSM-5 does agree with abused women that their male abusers are suffering from a psychiatric condition: intermittent explosive disorder.

Here are the diagnostic criteria:

A: Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals [sic—one is tempted to add an exclamation mark] occurring within a 12-month period.

B: The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.

C: The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).

D: The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning.

Elaborating slightly, but not much, on the diagnostic features, the DSM-5 says:

The impulsive (or anger-based) aggressive outbursts in intermittent explosive disorder have a rapid onset and, typically, little or no prodromal period. Outbursts typically last for less than 30 minutes and commonly occur in response to a minor provocation by a close intimate or associate. Individuals with intermittent explosive disorder often have less severe episodes of verbal and/or nondamaging, nondestructive or noninjurious physical assault. . . . Regardless of the nature of the impulsive aggressive outburst, the core feature of intermittent explosive disorder is failure to control impulsive aggressive behavior in response to subjectively experienced provocation.

Leaving aside the question of why the diagnosis should require three rather than two or four behavioral outbursts in 12 months (or, for that matter, in six or 18 months), the women’s belief that their male attackers suffer from a bona fide psychiatric—indeed, physiological—condition, requiring treatment, is likely to find reinforcement in the following:

Research provides neurobiological support for the presence of serotonergic abnormalities, globally and in the brain, specifically in areas of the limbic system (anterior cingulate) and orbitofrontal cortex in individuals with intermittent explosive disorder.

To call the habit of losing one’s temper and destroying things or hurting people a medical condition (from which, according to the DSM-5, 2.5 percent or so of the adult population suffers in a given year) empties it both of meaning and moral content, all in the service of a spurious objectivity. The notion of an outburst of temper grossly out of proportion to whatever provoked it implies moral judgment as to what constitutes appropriate and inappropriate displays of anger. Appropriateness is an irreducibly moral concept, requiring conscious judgment; no number of functional MRI scans, of the amygdala or of any other part of the brain, will assist in that judgment.

The nearly complete exclusion of the meaning of behavior from diagnoses turns psychiatry into a merely bureaucratic process, in that each diagnosis will have its prescribed, reimbursed—though not necessarily effective—treatment. Incoherence often results. To qualify as intermittent explosive disorder, the DSM-5 asserts, an individual’s outbursts should not have tangible ends, among them power and intimidation. Yet if we exclude such ends, it becomes inexplicable as to why outbursts should commonly occur in response to a minor provocation by a close intimate or an associate. To be devoid of tangible ends, the outbursts would have to occur completely at random, and they seldom do, certainly not among 2.5 percent of the population. The editors seem to have reflected little on the meaning of their own work.

It is easy, of course, to lampoon psychiatric nosology—the system for classifying disorders—and to underestimate the difficulty of producing such classification. After all, no objective laboratory markers or correlatives of psychiatric disorder exist. Thomas Szasz, a brilliant but dogmatic polemicist (as well as a professor of psychiatry), overcame this problem by denying that psychiatric disorder existed. According to Szasz, bizarre, distressing, or harmful behavior was either the result of an objectively observable pathology—hypothyroidism, say, or hypoglycemia, Cushing’s syndrome, or a brain tumor—or the patient was wholly responsible for it and suffered from nothing but a moral defect. In fact, the ability to recognize organic pathology is one reason psychiatrists should first be physicians, though admittedly many soon lose their medical skill and, worse still, instinct.

Nature seems to abhor not only a vacuum but also a category. Consider the so-called gambling disorder, which has such features, according to the DSM-5, as preoccupation with gambling and jeopardizing important aspects of life in order to continue gambling. Compulsive gambling may develop during the course of Parkinson’s disease and can sometimes be treated by neurosurgery. But the great majority of people with the putative gambling disorder will have no discernible brain pathology—discernible, at least, by current methods—to account for their behavior. There is, of course, no a priori reason that pathological causes of bizarre conduct or psychological functioning should not be found in the future; a disease does not become a disease only when its cause is understood. General paralysis of the insane was general paralysis of the insane before its cause—a late complication of infection by syphilis—was discovered. As Bishop Butler said, “Everything is what it is and not another thing.”

The overlap between straightforwardly pathological conditions (in Szasz’s sense) and those that result from social, psychological, or personal factors, or from bad moral choices, suggests that psychiatrists should show discretion in what they regard as genuine illness. The state of ignorance in which psychiatrists now practice, which will probably endure, ensures that they will often be wrong; but no one who has encountered, say, a manic in full flight is likely to doubt that he is in the presence of illness. But nor would it be easy, then, to see so-called factitious disorder, which consists of “falsification of physical or psychological signs and symptoms, or induction of injury or disease, associated with identified deception” in quite the same light: that is, to grant the same status to someone pretending to be ill as to someone genuinely ill.

Yet this is precisely what the DSM-5 does, establishing its authors’ lack of common sense, the quality that psychiatrists, perhaps more than any other kind of doctor, need. The manual’s lack of common sense would be amusing were it not destined to be taken with superstitious seriousness by psychiatrists around the world, as well as by insurers and lawyers.

The section of the volume devoted to personality disorders proves the point. Among the criteria for personality disorders in general are the following:

A: An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, in fields such as thought, emotion, interpersonal relations and impulse control. . . .

B: The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C: The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.

D: The pattern is stable and of long duration.

The DSM-5 then informs us that more than one in seven people have such a lifelong disorder—adding up to 45 million Americans and even more Europeans. These astonishing numbers give the authors not a moment’s pause (any more than does the fact that their own prevalence rates suggest that the average American suffers from more than two psychiatric disorders in any one year). Several undesirable characteristics must be present in an individual for a diagnosis of personality disorder to apply. Considering those characteristics, and that such a significant portion of the Western population supposedly exhibits many of them, either a mass outbreak of human nastiness and inability to deal with everyday life must have occurred, or the whole business of diagnosis must be dubious or even ridiculous.

Here is a random list of some of the characteristics that, in the DSM-5, make up personality disorders of various kinds:

Unjustified suspicions that others are harming, exploiting or deceiving.

Persistently grudge-bearing.

Detachment from social relations and limited expression of emotion.

Behavior or appearance that is odd, eccentric or peculiar.


Persistent irresponsibility.

Indifference to risk to self or others.

Irritability and aggressiveness.

Lack of remorse.

Recurrent suicidal behavior, gestures or threats, or self-mutilation.

Inappropriately intense anger, frequent displays of temper.

Rapidly shifting and shallow expressions of emotion.

Use of physical appearance to draw attention to self.

Self-dramatization, theatricality.


Requirement for excessive admiration.

Sense of entitlement.

Interpersonal exploitativeness.

Lack of empathy.

Enviousness of others.

Arrogance and haughtiness.

Unwillingness to become involved with people.

Sense of social ineptitude and inferiority.

Avoidance of risk.

Difficulty in expressing disagreement with others because of fear of disapproval, i.e., pusillanimity.

Feeling of helplessness when alone.

Preoccupation with details, rules, lists, order, organization or schedules.

Excessive devotion to work.

Over-conscientiousness or scrupulousness.

Reluctance to delegate.

Rigidity and stubbornness.

The diagnoses for most of the disorders require at least four of the undesirable characteristics to be present, predominant, and persistent. One is reminded of the King of Brobdingnag’s view of Gulliver’s countrymen: “I cannot but conclude the bulk of your natives to be the most pernicious race of little odious vermin that nature ever suffered to crawl upon the surface of the earth.” Lest anyone object that “only” one in seven people suffers from personality disorders, and that therefore the King of Brobdingnag’s opinion of Western humanity—that it suffers from the “worst effects that avarice, faction, hypocrisy, perfidiousness, cruelty, rage, madness, hatred, envy, lust, malice, and ambition, could produce”—is not relevant, one must add that, for the DSM-5, people with personality disorders are merely the most extreme exemplars of their type. And if only the extremes have four or more undesirable and frequently horrible dominating characteristics, many individuals must have one, two, or even three such characteristics. If the DSM-5 reflects the American Psychiatric Association’s views, then that organization clearly views humanity with Swiftian distaste. Yet its distaste is not that of a disappointed lover (and certainly not expressed with Swift’s genius) but is motivated, one suspects, by the hope of an endless supply of patients. For those with psychiatric disorders need psychiatrists.

The tendency of psychiatric diagnosis to colonize human experience is illustrated by the DSM-5’s shifting diagnostic criteria for post-traumatic stress disorder (PTSD). There is no recognition in the manual that the very act of labeling an experience pathogenic may encourage the pathology—in other words, that the human mind often reacts as it is expected to react—and that thereby the psychological fragility of human beings is increased. In the DSM-III (revised), a person diagnosed as suffering from PTSD must have:

experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one’s life or physical integrity; serious threat or harm to one’s children, spouse or other close relatives and friends . . . or seeing another person who has recently been, or is being, seriously injured or killed as a result of an accident or physical violence.

In the DSM-5, by contrast, “learning that the traumatic event(s) occurred to a close family member or close friend” is sufficient to trigger PTSD. The number of those susceptible to the disorder then expands considerably, for it can now strike those who haven’t experienced or witnessed anything traumatic themselves. The DSM-5 still excludes witnessing traumatic events on television or through other electronic media as a cause of PTSD, but doubtless by the next edition, to the delight of therapists and lawyers everywhere, such exposure will be enough. There is no plausible reason that it would not be sufficient, if merely learning about a trauma that happened to someone else can bring on the disorder. Since it is increasingly the view of the law and of the welfare system that psychological injury is to be treated exactly in the same way as physical injury (a thoroughly corrupting doctrine), the DSM will exert its baleful influence on society.

Psychiatric diagnosis—more overblown, all-inclusive, and shallow in the DSM-5 than ever before—has almost driven the word “unhappy” from the English lexicon. This is hardly surprising: according to the DSM, depression can be diagnosed after only two weeks. Among the thousands of patients who consulted me over a period of 15 years, only three whom I can recall ever used the word “unhappy” (and one was a prisoner, who told me, “I’m not happy in this prison, Doctor”). By contrast, thousands said that they were “depressed.”

The semantic change is significant. The word “unhappy” is an implicit call to self-examination; the word “depressed” is, at least nowadays, a call to the doctor. It is no coincidence that the age of the DSM should coincide with a tenth of the population’s taking antidepressants—drugs that, for the most part, are placebos when not outright harmful. None of this excludes the possibility, of course, that some diagnoses will run afoul of pressure-group politics by the time the DSM-6 comes out. How long, for example, can gender dysphoria disorder survive every right-thinking person’s moral duty to celebrate transsexualism?

The DSM is ultimately an instrument for weakening human resilience, self-reliance, fortitude, and resolve. It turns human beings into mechanisms, deprives their conduct of meaning, and makes them prey to entrepreneurs of human misery. The authors, one could say, suffer from PNOD—psychiatric nosology overvaluation disorder—the criteria for which are as follows:

A: The grandiose belief that all human weakness can and should be divided into valid diagnostic categories.

B: At least two of the following: a firm and unshakable belief that all human distress arises from malfunctioning serotonin metabolism; a firm and unshakable belief that functional MRI scans will soon teach humans how to live; a firm and unshakable belief that the seven deadly sins have been scientifically superseded by psychiatric diagnoses.

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