City Journal – Autumn 2013
Vol. 23, No. 4
By Theodore Dalrymple
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. Read the rest of the article here: http://www.city-journal.org/2013/23_4_otbie-psychiatry.html