Today we'll talk about psychological disorders, or psychopathology. It's a really interesting question: What kinds of behavior exceed the normal range of behavior for human beings? Which behaviors are truly pathological, as opposed to simply uncommon or exceptional? If you think of a time when you encountered a person who had a strange behavior, how would you determine whether it was pathological or not?
A psychological disorder is a mental condition characterized by symptoms that create significant distress, impairing work, family, school, and/or relationships, and leading to significant risk of harm. The symptoms of these disorders are cognitive, emotional, and behavioral.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) [Wikipedia: DSM] is the tool that psychiatrists and clinical psychologists have today for diagnosing individuals who have aberrant behavior. It's a structured list of symptoms for the disorder, but it's not biomarkers – there's no blood test for intermittent explosive disorder or schizophrenia. It's things that people report thinking or feeling, or behaviors that others report. But there aren't hard and fast rules for each diagnosis.
So let's talk a little about the DSM. What does it feel like to have a book of diagnostic criteria like this? Does this seem like a good strategy from a medical standpoint?
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It's better than nothing. It allows psychiatrists to be more objective in their diagnoses, since there is a list of criteria that you have to meet. I would still call it "guided subjective diagnosis."
Some of the criteria, however, can't be measured objectively, like "feels tired all the time." That can mean different things to different people. It's not like a blood test with a quantitative result.
But others have argued that people are so complex that you can't just pin one diagnosis on a person, you have to treat them as a whole person and use your professional judgment.
As the DSM has gone through multiple versions, many of the disorders have been split into multiple subtypes, like "generalized anxiety disorder" and "social anxiety disorder" and so on. Maybe this is only meaningful if they call for different treatments.
It depends on the beliefs of the committee of people who write it, even though it's a consensus of many professionals. I've heard that in the next version the description of Autism Spectrum Disorder will be more conservative, and that people who meet the Asperger's diagnosis won't anymore. And this will affect who gets treatment and who doesn't. The question there is whether we're using resources to treat people who are really just a little bit different.
It also depends on the politics and the society at the time. In the Soviet Union, protesters were institutionalized for speaking against Marxism. And here it was only in the 1980's that homosexuality was removed from the list of disorders, while Asperger's was added.
I think whether or not something is classified as a disorder should depend on whether it has a negative impact on your life. Being homosexual doesn't necessarily have that; it's a function of the society you live in and whether it treats it as a problem.
On the other hand, the kids I worked with who had Asperger's wouldn't get the services their families wanted unless they had the diagnosis. So there's a compelling interest in keeping disorders in the DSM.
But the problem with certain labels getting a lot of attention is that there's more likely to be misdiagnosis or over-diagnosis of them. It can also create a self-fulfilling prophecy. If you come in with a few symptoms of a disorder and get the label, you might start to "own" that label and begin to adopt the other symptoms.
Let's talk about cultural specificity of psychological disorders. Something we're familiar with here in this country is eating disorders such as anorexia nervosa and bulimia. People with these disorders have pathological psychological and behavioral relationships to food, which cause serious physiological damage. They seem to come down to a disorder of body image, so they're especially dangerous for teenagers. And they don't seem to exist in societies where food is scarce. So we see disorders like autism, schizophrenia, and depression across cultures and across time; they're sort of a general part of the human condition. Are eating disorders the same? Based on your knowledge of the world, are they universal, or are they culturally-specific?
Well, let's introduce a couple of other disorders from other parts of the world and consider whether we have anything similar. One example is Wendigo psychosis, in which a person is overcome by the desire to eat human flesh. And it's deeply disturbing, first because you desire to eat human flesh, and second because you recognize that something's wrong with you. Is this anything that you've heard about in American society?
Another is something called running amok, which is actually a phrase that's entered our language. It derives from a psychological disorder in Malaysia in which a person suffers some sort of social embarrassment. They first exhibit some depressive-like symptoms, but then have a violent outburst. As far as I know, they either end up killing themselves or being killed. Do we see examples of this? To me, it sounds like a hostage situation in which a person goes through a period of depression, then does something crazy like taking hostages in a bank or attacking a school. They often kill themselves or are killed by the police. So by analogy, it seems similar, even though the societies may be very different.
Can you think of other examples? How would you decide whether a disorder is culturally bound? Should the DSM label them as such?