by Dr Michael FitzpatrickEarly commentary on the fifth edition of the Diagnostic and Statistical Manual (DSM V) of the American Psychiatric Association - due for publication in 2013 - has focused on the new range of sexual disorders. These include "absexuality" (the Mary Whitehouse syndrome of excitement at being appalled at displays of pornography), "hypersexuality" (the affliction of Tiger Woods, film stars and premiership footballers), and, so that nobody feels left out, "sexual arousal disorder" (experienced by people who are just not interested).
Early commentary on the fifth edition of the Diagnostic and Statistical Manual (DSM V) of the American Psychiatric Association - due for publication in 2013 - has focused on the new range of sexual disorders. These include "absexuality" (the Mary Whitehouse syndrome of excitement at being appalled at displays of pornography), "hypersexuality" (the affliction of Tiger Woods, film stars and premiership footballers), and, so that nobody feels left out, "sexual arousal disorder" (experienced by people who are just not interested). Many commentators have complained about the use of pompous psychobabble for what appear to be familiar forms of individual dysfunction, such as "sluggish cognitive tempo disorder" and "post-traumatic embitterment disorder".
The need for a diagnosis
Yet there has been little questioning of the further expansion of the scope of psychiatric diagnosis. In his celebrated 1967 A Fortunate Man: A story of a country doctor, John Berger emphasised the therapeutic value to the patient of having a complaint "recognised" in the form of a diagnosis that was "defined, limited and depersonalised". The problem today is that we can no longer claim that giving patients the sort of labels offered in DSM V will make them stronger.
Whereas in the past mental illnesses were few and clearly defined, the new disorder labels are both more numerous and more diffuse. In 1952 the first edition of DSM (DSM I) recognised 106 categories of disorder; by 1994 and the publication of DSM IV, this number had expanded to 297. It is clear that DSM V will include many more disorders and they will apply to more people, stretching beyond the "one in four" currently deemed to be in need of psychiatric attention. The inclusion in the DSM V draft of new categories of being at risk of psychosis or dementia further extends the reach of psychiatry.
Blurring the boundaries
The popularity of the concept of a continuum of mental disorder results in a further blurring of the boundary between the normal and the abnormal.
Whereas diagnoses previously suggested the limited character of the condition, modern disease labels imply disorders that are unrestricted in the scope of the symptoms to which they give rise and in the duration of their effects. Post-traumatic stress disorder or recovered memory syndrome, for example, can be expressed in the widest variety of symptoms, which may arise long after the traumatic events believed to have triggered them. There is also a widespread conviction that these may continue indefinitely as people are "scarred for life" by past traumas. Today's sufferers from addictions or compulsions, expanded in the DSM V draft to include binge-eating and gambling, can never claim to have been cured; they live their lives "one day at a time" in an ongoing process of "recovery".
The depersonalised character of traditional diagnoses allowed the sufferer to objectify the condition as something "out there", perhaps a somewhat forced abstraction, but one with some pragmatic value. By contrast, a diagnosis like "negativistic personality disorder" is inescapably personal and subjective in character. Every sufferer exhibits a different range of symptoms, and there is no way of objectively confirming or monitoring the course of the illness.
Labels that prolong incapacity
The net effect of the dramatic expansion in the range of psychiatric diagnosis is that, instead of empowering the patient, these labels are more likely to intensify and prolong incapacity. It also reflects a profound demoralisation of society and a deep crisis of subjectivity.
In her fierce polemic against the influence of psychodynamic theories in social policy in the 1950s Barbara Wootton argued that when the boundary of psychiatric diagnosis changes, "the frontier of responsibility shifts". She was worried that "we are travelling steadily towards abandoning the concept of responsibility". I fear that if she had lived to read the DSM V draft she might have experienced an outburst of "intermittent explosive disorder".
Michael Fitzpatrick is a GP in Hackney and author of Defeating Autism: A Damaging Delusion, published by Routledge
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The need for a diagnosis
Yet there has been little questioning of the further expansion of the scope of psychiatric diagnosis. In his celebrated 1967 A Fortunate Man: A story of a country doctor, John Berger emphasised the therapeutic value to the patient of having a complaint "recognised" in the form of a diagnosis that was "defined, limited and depersonalised". The problem today is that we can no longer claim that giving patients the sort of labels offered in DSM V will make them stronger.
Whereas in the past mental illnesses were few and clearly defined, the new disorder labels are both more numerous and more diffuse. In 1952 the first edition of DSM (DSM I) recognised 106 categories of disorder; by 1994 and the publication of DSM IV, this number had expanded to 297. It is clear that DSM V will include many more disorders and they will apply to more people, stretching beyond the "one in four" currently deemed to be in need of psychiatric attention. The inclusion in the DSM V draft of new categories of being at risk of psychosis or dementia further extends the reach of psychiatry.
Blurring the boundaries
The popularity of the concept of a continuum of mental disorder results in a further blurring of the boundary between the normal and the abnormal.
Whereas diagnoses previously suggested the limited character of the condition, modern disease labels imply disorders that are unrestricted in the scope of the symptoms to which they give rise and in the duration of their effects. Post-traumatic stress disorder or recovered memory syndrome, for example, can be expressed in the widest variety of symptoms, which may arise long after the traumatic events believed to have triggered them. There is also a widespread conviction that these may continue indefinitely as people are "scarred for life" by past traumas. Today's sufferers from addictions or compulsions, expanded in the DSM V draft to include binge-eating and gambling, can never claim to have been cured; they live their lives "one day at a time" in an ongoing process of "recovery".
The depersonalised character of traditional diagnoses allowed the sufferer to objectify the condition as something "out there", perhaps a somewhat forced abstraction, but one with some pragmatic value. By contrast, a diagnosis like "negativistic personality disorder" is inescapably personal and subjective in character. Every sufferer exhibits a different range of symptoms, and there is no way of objectively confirming or monitoring the course of the illness.
Labels that prolong incapacity
The net effect of the dramatic expansion in the range of psychiatric diagnosis is that, instead of empowering the patient, these labels are more likely to intensify and prolong incapacity. It also reflects a profound demoralisation of society and a deep crisis of subjectivity.
In her fierce polemic against the influence of psychodynamic theories in social policy in the 1950s Barbara Wootton argued that when the boundary of psychiatric diagnosis changes, "the frontier of responsibility shifts". She was worried that "we are travelling steadily towards abandoning the concept of responsibility". I fear that if she had lived to read the DSM V draft she might have experienced an outburst of "intermittent explosive disorder".
Michael Fitzpatrick is a GP in Hackney and author of Defeating Autism: A Damaging Delusion, published by Routledge
Recent articles by Michael Fitzpatrick
Social pedagogy waffle
Swine flu morass
Yeah. It's a disgrace what has happened to Tiger but you still have to respect him as a sports man. Just because he is a great competitor doesn't mean you have to be fond of him as a person! There are tons of individuals who I respect for their work but wouldn't want to meet them!