Mental disorders aren't necessarily valid

Great Debates
1

Okay. This is an attempt to resurrect Zenster’s thread on ODD, which has indeed become convoluted and somewhat off-topic.

The original argument in that thread concerned whether or not Oppositional Defiant Disorder is unreasonably used to pathologize the behavior of problem children.

I offer the following arguments:

  1. The diagnostic criteria for ODD take cultural norms for granted.

  2. The criteria also make use of extremely vague concepts like “clinically significant impairment”, which does not have a clear or immediately obvious interpretation.

  3. They presume that the problem is necessarily with the child instead of with the environment.

Moreover, I claim that these and similar problems exist in the criteria for mental disorders in general. Although demanding empirical proof that a condition is a distinct and objective medical disorder is unreasonable, I assert that even elementary standards are not met for the vast majority of mental disorders.

Furthermore, the way these conditions are treated and perceived isn’t justified either, but that’s a more involved topic that was at least partially responsible for the derailing of the first thread, so I won’t bring it up unless someone else does so first.

2

Not having read the linked thread, perhaps it might be useful to begin with mental disorders which are definitely valid and go from there. So, do your three points apply to schizophrenia and depression (clinical or bipolar)? Is there a question as to the “validity” of such recognised disorders as Obsessive Compulsive Disorder and anorexia?

I’m not sure quite what it is that’s up for debate here - it might be better to focus on specific examples.

3

My complaint is that virtually ALL of them are unjustified. (There are a few which are genuine medical conditions and are included in the DSM because they can be confused with psychiatric disorders.)

Let’s look at one example: atypical depression. It’s almost the inverse of archetyped depression: instead of sleeping more, people often sleep less; instead of eating less and losing weight, people tend to eat more and gain weight. Almost the only factor in common is unhappiness – and that both types respond equally to standard therapies, including antidepressant treatments.

On a related note, consider atypical antidepressants. The primary neurotransmitter effects of these drugs are significantly different from “normal” antidepressants, and we have no reliable way of determining who will respond to them instead of normal antidepressants.

Yet many people insist that antidepressants treat the underlying neurochemical problem that supposedly causes depression.

4

DSM?

So, you are contending that bipolar depression is valid, but atypical depression is not?

Is permanently unhappiness not a disorder in itself?

You’ll have to help me out a little here, *Aide. While I have no little experience of mental illness (my mother has suffered bipolar depression all of my life) I am not well up on standard psychiatric diagnostic practise.

5

I’ll offer the following rebuttals:

  1. the introduction to the DSM 4 states that “A clinician who is unfamiliar with the nuances of an individual’s cultural frame of reference may incorrectly judge as psychopathology those normal variations in behavior, belief, or experience that are particular to the individual’s culture.” -see the section marked “Ethnic and Cultural Considerations” pp. xxiv
    Cultural competence is key in mental health education these days, I personally credit social work for that one.

  2. Also see the introduction to the DSM pp. xxii “Use of Clinical Judgment”
    “The diagnostic categories, criteria, and textual descriptions are meant to be employed by individuals with appropriate clinical training and experience in diagnosis. It is important that the DSM 4 not be applied mechanically by untrained individuals.”
    I recommend reading the whole paragraph.

  3. No, they don’t. That’s your presumption, not that of the diagnosis or the book or the profession. You’ve had a couple of professionals tell you now (in the aforementioned other thread) that there is no “one” cause, that the disorder is likely caused by an interaction of variables; and you’ve provided no proof of this supposed assumption.
    If you can point to the specific page, or research study that highlights this presumption, I’d be glad to disagree with it.

6

**

To be more specific: a measure, scale, or set of criteria is reliable when its results have a clear relationship to the test data; in other words, if the test tends to give the same result when it’s fed similar data, or if multiple people each applying the test to the data come up with the same result, it’s reliable.

Validity requires that the results of the test have something to do with what it’s supposed to be testing. It’s much harder to be valid than to be reliable.

To use an analogy: being able to hit the same spot on a dartboard over and over is reliability. Being able to hit the bullseye is validity.

I have no particular reason to think that the criteria for bipolar depression are any more valid than the criteria for other mental disorders. I don’t question that people experience tremendous anguish and irrational exuberance in cycles; I do question our ability to determine which people have something objectively wrong with them.

I’m very sorry to hear that.

In case you didn’t get the reference: the DSM is the Diagnostic and Statistical Manual of Mental Disorders, which is currently in its fourth incarnation if I’m not mistaken.

7

** Which is precisely the problem.

Why is a person who claims God told him to sell his house considered insane if he grew up in one religious tradition and crazy if he grew up in another?

How do we determine that the clinician has “incorrectly” judged someone to be suffering from psychopathology? What standards define psychopathology, and how can we examine them? (My answers: there really aren’t any, other than social agreement, and we can’t.)

** Precisely. The DSM doesn’t actually define the mental disorders at all – the actual operational definitions are learned implicitly and can’t be objectively analyzed.

** But that’s not what I’m arguing. (I should be used to your misunderstandings by now.)

I am pointing out that there are no clear-cut disorders, which is why so many different factors are related to them. The presumption that occurs very often in clinical interaction is that there is an underlying physiological problem in these conditions can presents with a diverse set of symptoms, but that presumption has no basis in known science.

8

I want to believe that everyone really knows what they are doing and that all these new disorders that have appeared over the last 20 years are real maladies that are treatable by well researched means.

However, as time goes by, it’s getting harder and harder to believe this. I’ve still not found any proof that any psychological disease is really a disease; and some that I was sure were real are now being proved otherwise (or unsure, such as schizophrenia).

I think what has happened, to my layman’s eyes, is that in the beginning there were some people that acted so outside the norm of the current culture that they needed to be talked to or set away from others for their own or our sake. Different treatments were designed to help them understand how to live in society, and so the studies grew. Now people with other issues began to be sent to or seek out the people who studied these issues.

However, as we’ve continued down that path, the norm of the current culture has been redefined into more and more narrow definitions. As we continue, any person who doesn’t act as a respectable, happy, and productive member of society will have the option of seeking therapy or drugs to make them conform more.

So, someone who was once considered lazy, will now be able to seek help for his laziness and be “cured”. Someone who was never able to pay attention in class will be able to seek help for that. Soon, if you feel you lack ambition, or are not giving enough, you too will be able to seek help.

Is depression a real issue? Certainly. If someone is mean, no doubt they are mean. If we want to alter that behavior, whether it be through talking or drugs, I’m sure we will find a way.

The real problem is where do we draw the line, or do we need to draw a line at all? Personally, I think we are missing too many worthwhile negative issues by fixing these problems. I also feel we are losing some of our cultural flexibility by so rigidly designing normality. Much of today’s 1st world citizenry are used to getting things fixed for them with as little work as possible, so I don’t see this changing anytime soon.

Basically, I wouldn’t want to stop someone from seeking help for an issue they feel is adversely affecting their life. But I do wish it would happen less. I also fear the stigma and passing on of responsibility someone might feel when diagnosed with an issue that a generation ago would have just been a personality trait.

9

This “ODD” sounds an awful lot like a mental illness described by Dr. Samuel Cartwright: “Dysathesia aethiopica” had symptoms that included destroying property, disobedience to authority figures, talking back, and refusing to do assigned tasks.

Dr. Cartwright was writing in the 1800s about the behavior of “uppity” slaves. OBVIOUSLY these slaves HAD to be mentally ill to do this sort of thing.

He also decided that escape was a certain diagnostic of the mental illness drapetomania, the clinical urge to escape from slavery.

Oddly enough, I can’t find either drapetomania or dysathesia aethioptica in the DSM-IV, for some reason.

10

I’m a bit confused. Are you saying that, if we can’t measure something, then it can’t exist? Not trying to put words in your mouth, just trying to understand.

My sister has a mental condition. It’s very obvious. It’s not like someone being lazy. Her mind does not work right. Is your “issue” more with diagnosis of “bipolar”? Can we agree that her mental imbalance is “valid”? I’m just trying to see your point.

11

  1. It’s a problem that the DSM warns against cultural bias? Or is it a problem that the mental health community is focusing heavily (my experience) on cultural issues?

  2. You’re assuming this, unless you can demonstrate where in the training of a therapist or other diagnostician we are taught this. The person isn’t considered to be “crazy” or “insane” solely based on hearing god tell him to sell his house; at least not by me.
    This is why diagnosis can’t be reduced to a checklist, nor should it untill technology is much further advanced.

  3. If you already “know” the answer, there’s no use in addressing the questions or even asking them. You’re wrong, unless of course you have proof.

  4. I’ts not a question of “can’t” be objectively analyzed at all, it’s to what degree they can be objectively analyzed. Is there anything in this world that can be analyzed objectively by human beings at all? (I’m really asking, I can’t think of anything that is completely devoid of subjectivity).

  5. Is this opinion or fact? If it is opinion, I have no problem with it. It seems to be opinion.

  6. (restraining myself here) How do you know what presumptions are made in clinical interactions?

I can tell you that as a therapist and diagnostician, I don’t presume that in my daily clinical interactions. I can tell you that I wasn’t taught to do so, it wasn’t on my licensure exam, and presumption of a physiological condition isn’t encouraged in my clinical supervision sessions.

I can tell you that I think that any presumption is likely to lead to problems in clinical interactions and that I avoid them. I can also tell you that I was taught this in school and it is reinforced in my work environment.

Now, I ask again; how do you know? You don’t get to make the second part of that statement until you first prove that the presumption is made. (strawman, right?)

12

** It’s a problem that two people with the exact same weird beliefs can be perceived differently depending on what culture they exist in. A person setting his hair on fire to rid himself of evil spirits would probably be diagnosed as psychotic. But once it was learned that such a practice is common within the culture he grew up in – hey, he’s perfectly normal!

Someone who hears the voice of God telling him things that fit into generic religious conventions is a saint. Someone who hears the voice of God telling him things that don’t fit into his religion is insane.

** Oh brother. This isn’t an assumption – it’s a problem.

13

Define “weird” in a way that is UNIVERSALLY valid, in all places, at all times, for all people, forever and ever, with no bias from your own culture.

14

TVAA-
you first have to demonstrate that this same person is diagnosed with a mental illness in one context, not another, and with only the information you provided. Then you get to call it a problem.

Otherwise, you’re assuming. You’re asking people to believe, without proof or qualification, that this “problem” exists and then trying to take the mental health profession to task on a problem that doesn’t exist.

A person setting his hair on fire, I’ll admit, takes him quite a ways toward a diagnosis; however, any diagnostician who bases a diagnosis solely on this information… well, first prove that it’s happening, then I’ll ask you for his license # and how to contact the appropriate governing board.

Again, I have no problem with you having opinions, as long as you don’t misrepresent them as fact.

And for those of us who are keeping score, did you conceede that you don’t know what happens in clinical interaction?

15

I just wanted to answer one question:

Mathematics.

16

As somebody with a mental disorder, and who feels ambivelently towards this disorder, this subject is on my mind a lot.

I think, TVAA, is that you are looking for rocket science. But psychology and psychiatry are not at that point. We are dealing with one of the most complex and unknown systems in the universe- the human brain. Added to that, there is human consciousness, which is about as mysterious as anything can get. So while psychology and psychiatry act like sciences, they are dealing with a huge number of unknowns in all of their equations. Maybe one day they will be at the point where they can factor in culture factor X to upbringing value Y to brain structure value Z to get disorder A. But they are nowhere near there yet.

And still, people suffer.

So they do the best they can. Right now mental disorders are considered something to worry about when they start bothering people- before that point they are just quirks or personality traits. It’s imprecise, but it’s a pretty workable solution. And a lot of treatments are still pretty mysterious. But they seem to work. So we go with them. Yeah, a lot of shooting in dark goes on. But it’s the best we can do.

I do agree that it is good to keep a critical eye on things. There are a lot of details to work out regarding what is essential to a person, what treatment or lack of treatment a person has a right to, and how mental disorders ought to be considered in society.

For example, one trait of my disorder is that people with this disorder tend to go off their medications. From this side of the fence, it’s because the way one thinks seems pretty essential, the medications are pretty clumsy and the disorder is often pleasurable to some degree. But from the outside, it looks like all these people going off their meds are just crazy and probaby ought to be forced to take the meds for everyone’s own good. I know I get a lot of pressure for not being on meds- but the truth is that I’m just not sure how I feel about it all yet and I think i have a right to my thoughts, disordered though they may be.

Anyway, the idea is that it is all suprememly complicated, and you are looking for a simple elegance that just isn’t there. In the meantime, people still suffer and something ought to be done for those that seek some kind of peace with their mind.

17

I’m not so sure. If we had the ability to make everyone behave exactly the same, should we make that ability available?

Everyone suffers in life, should we remove it all if we were able?

If not, then it goes back to where we draw the line. In reality, we are not drawing any line and we are just going towards removing any suffering or differences that we are able. I’m not sure this is a good thing.

Certainly I think there is level of difference or suffering that we should attempt to alleviate. You’re right about it being very complicated though. For example, suppose we help someone, how much do we help them? Do we make them perfect if we are able, or only give them enough therapy or drugs to make them barely tolerate life?

18

Replace “person who suffers” with “person who is unable to function”.

The point is not “oh, these people are so unhappy”. The point is “these people cannot balance a checkbook, they cannot raise a child, they cannnot XYZ”. We should want these folks to be self-sufficient. They want to be self-sufficient.

Does it bother you that we encourage paraplegics to use wheelchairs? The point is not to make people “perfect”, it is to restore function.

By the way, TVAA, I’m still waiting for your response to my questions.

19

** No. I’m saying that if we can’t detect something, we should be very, very cautious about claiming it exists. Not quite the same thing.

My point is that we don’t know what’s wrong with your sister. Well, in an obvious sense, your sister probably alternates between periods of deep melancholy and irrational exuberance, so we can say that’s wrong, but we have no understanding of the nature of what causes those behaviors or how the available treatments actually work.

20

** And I have no objections to providing these people with whatever therapy they desire. Really - I tend toward laissez-faire libertarianism when it comes to medicine. As long as they’re accurately informed about the nature and effects of treatment, they can consent to whatever they want.

But I worry that our willingness to proclaim a problem a disease far outstrips our ability to back up and justify such claims. I worry about the people who are forced into some kind of treatment, or persuaded into accepting therapy because they’re given misleading and incomplete information.

** And in some cases, in extremely crude and dangerous ways.

Sorry, I didn’t notice your post at first. I can’t be everywhere, you know.