There have been stories here and there about the upcoming DSM V for several months now. The most recent, in the LA Times, takes a somewhat optimistic view --
"Over the next 18 months, psychiatrists will hammer out a draft of the fifth edition of the American Psychiatric Assn.'s Diagnostic and Statistical Manual of Mental Disorders, more commonly called DSM-V. Nowhere have the discussions been more heated, the ramifications most vividly foretold, than here at the organization's annual meeting.
Some psychiatrists warn that the tome runs the risk of medicalizing the normal range of human behaviors; others vehemently argue that it must be broad enough to guide treatment of those who need it.
But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.
Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described."
But this feels exceedingly rosy to me. Especially when there is consideration of adding bitterness, sub-clinical bipolar disorder and other variations of what many, including me, consider to be within the range of normal experience and behavior. And I cannot believe that there is real research evidence to establish these or many of the existing diagnostic categories as anything other than descriptions of clusters of behavior. Because all of the diagnostic categories rely on observer report, not tests or other diagnostic tools, because they simply do not exist. What we have now are lists of symptoms or behaviors -- display 6 out of 10, for example, and you fit the category; 5 and you don't. But that makes no sense. What is the difference between the two such that having slightly more symptoms means you are mentally ill -- and that term is an argument for another day -- and thus appropriate for treatment? Are habits -- like gambling or excessive time online -- really indicative of pathology? And why is making them mental illnesses in the best interests of patients, especially when there is no evidence of etiology for either one?
"Bitterness, which I define as a chronic and pervasive state of smoldering resentment, is one of the most destructive and toxic of human emotions. Bitterness is a kind of morbid characterological hostility toward someone, something or toward life itself, resulting from the consistent repression of anger, rage or resentment regarding how one really has or perceives to have been treated. Bitterness is a prolonged, resentful feeling of disempowered and devalued victimization. Embitterment, like resentment and hostility, results from the long-term mismanagement of annoyance, irritation, frustration, anger or rage. Philosopher Friedrich Nietzsche noted that "nothing consumes a man more quickly than the emotion of resentment."
Most mental disorders stem either directly from--or secondarily generate--anger, rage, resentment, hostility or bitterness. This is why I personally applaud the American Psychiatric Association's long overdue recognition of the debilitating and deleterious aspects of Post-Traumatic Embitterment Disorder (see my previous post on "The Trauma of Evil"). There is no question that, if left to fester unconsciously, anger, rage and resentment about having been traumatized become bitterness and hostility, which in turn give rise to self-defeating, sometimes passive-aggressive, destructive, vengeful or even violent behavior. Pathological embitterment is a dangerous state of mind that can and does motivate evil deeds. This attempt to include what I would categorize as another "anger disorder".
He has written several times now about his view of rage and anger and where they become pathological. And in some ways I see his point, especially vis a vis violent behavior, which he has discussed earlier. One example can be found here. But the tool of the DSM diagnosis is a very crude one and one which really does not discriminate by degree. And we have seen more disorders become spectrum disorders so that where normal behavior ends and pathological begins becomes more and more difficult to discern. Thus the concerns raised by Lane and others, including me.
In its discussion of post-traumatic embitterment disorder, the APA may have correctly gauged the mood of the country, but as usual it has ignored or shunted aside most of the explanatory context, to pathologize the individual in all of her or his frustrated grievance.
"They feel the world has treated them unfairly," says Dr. Michael Linden, a German psychiatrist who labeled the behavior. "It's one step more complex than anger. They're angry plus helpless."
Linden estimates that between 1% and 2% of the population is embittered, though he didn't specify whether that percentage increased during or immediately after the Bush years. Perhaps he should. Others reviewing his work note that PTED includes "a high degree of comorbidity [and] diagnostic uncertainty . . . : 66% adjustment disorder, 40% dysthymia, 34% generalized anxiety disorder, 18% social phobia, 18% agoraphobia, and 16% personality disorder."
But adjustment disorder, a highly elastic concept, is itself a capacious term to describe predictable, largely routine responses to stress. Why, then, is the APA discussing the inclusion of a new term that not only overlaps so strongly with existing "disorders," but also has so many obvious, identifiable causes in the world?
My alarm bells go off when understandable behavior -- like bitterness about things like the reversals of fortune many have suffered in the current economic downturn or political bitterness so common in the Bush years -- is made pathological. Because once something can be tagged as mental illness, it no longer has to be taken seriously. Questions like what does it mean that a significant segment of the population feels embittered about the future, already too seldom asked, become even less likely to occur, because it's about an illness, a disease. Whose interests are served by this?
And, as is mentioned in the LA Times piece, we also have the additional problem of conflicts of interest among those serving on the panel writing the DSM.