Those that tend toward introversion – often confused with shy individuals – face a number of difficulties (or challenges) each day. Many can circumvent the issues, sometimes more easily than other times. The following article addresses some of the more important considerations, especially as psychiatric entities attempt to pathologize introversion, shyness…One can certainly be pleased that this topic is being talked about more openly now…in the news, in professional journals…
. The first published attempt at cataloguing mental health in the United States appeared in 1917. The Statistical Manual for the Use of Institutions for the Insane was a slim 40-page treatise, dispersed to mental hospitals trying to describe their clientele. It included 22 varieties of “mental disease,” 15 of which were types of psychosis.
Decades passed. The return of soldiers from World War II — and the psychological issues they brought with them — caused the medical community to think more intently about categorizing those issues. In 1952, the American Psychiatric Association decided to create a new book. It would be dedicated solely to diagnosing mental illness. It would be called the “Diagnostic And Statistical Manual: Mental Disorders.” The DSM.
Not exactly a best-selling title, but then, it wasn’t meant to be a best-selling book. Outside of the mental health community in the United States, “Nobody much paid attention to it,” says Edward Shorter, a medical historian at the University of Toronto, and the author of “How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown.” There was already an international document, the International Classification of Diseases, that was in use worldwide.
Besides, in the early 1950s, psychiatry was still dominated by psychoanalysis, by the ghost of Sigmund Freud, who had died in 1939. “Nobody was interested in the classification of illness,” Shorter says. People were interested in dream analysis. In the mysterious vagaries of the subconscious, in the interplay between the id, the ego and the superego. The predominant diagnoses at the time were anxiety and “neurotic depression,” illnesses which lent themselves especially to the faddish dream interpretation of the period.
Ironically, the same year that the first DSM was released, in all of its psychoanalytical glory, the drug chlorpromazine became available in France. The first edition of the DSM was a new book representing old concepts — the “last gasp” of psychoanalysis, Shorter says. Chlorpromazine, sold as Thorazine in the United States and the first drug specifically market as an anti-psychotic, represented the dawn of psychopharmacology, the beginning of a new era.
What happened: In 1972, a team of British and American researchers published a study called “Psychiatric Diagnosis in New York and London” that compared diagnoses from hospitals on each side of the Atlantic.
The study’s results were confusing: 62 percent of New York’s patients were diagnosed as schizophrenics, compared with only 34 percent of London’s test subjects. London doctors, on the other hand, declared 24 percent of their subjects to be suffering from depressive psychosis — a diagnoses given to only 5 percent of New York’s study participants.
The study illustrated a problem with diagnosis at the time: It wasn’t consistent, and it wasn’t repeatable. Psychiatrists were ostensibly using the same definitions but were arriving at different conclusions.
The second revision of the DSM had been more of an update than an overhaul, but in the mid-1970s, the DSM task force decided that the third edition would be a rigorous and ambitious reimagining of what a psychiatric manual could do. Columbia psychiatrist Robert Spitzer was tapped to act as chair, and he set about changing the DSM from a more descriptive document to a rule-bound field guide for classification.
Gone were the Freudian “neuroses” that had populated earlier editions. Introduced were guidelines to help clinicians from different facilities arrive at the same conclusions, writes Bob Whitaker in “Anatomy of an Epidemic,” a history of mental health in the United States. A practitioner could not, for example, declare someone to be experiencing a “major depressive episode” unless five of nine listed criteria were met.
Moreover, the DSM-III was a rhetorical revolution, expanding the number of potential diagnoses — and the terms people had available to describe their suffering — to 265. It neatly organized people and behaviors into tidy compartments, laying the groundwork for manuals to come, and for the future of psychiatry as a whole. One psychiatrist at the time, writes Whitaker, heralded the new DSM as the victory of scientific psychiatry: “The old psychiatry derives from theory, the new psychiatry from fact.”
To laymen, psychiatry can still come across as theoretical, more difficult to grasp than other branches of medicine: The difference between a bloody foot and a bruised soul. But over the course of its history, the DSM has been a mirror, reflecting whatever is ailing society and providing a vocabulary with which to discuss it. The language of the DSM has been embraced (misused?) by the masses, aiding in the self-description, self-labeling and self-analysis that have defined the 2000s and 2010s. We are “a little bit OCD,” with bosses who are “classic narcissists.” We are dating boyfriends who might have generalized anxiety disorder.
The DSM takes that bruised soul and gives it a name. Which gives us peace of mind.
If something is wrong with all of us, is anything wrong with any of us?
When the DSM-IV was released back in 1994, researchers didn’t know nearly as much as they know now about how the brain works. They didn’t know as much about circuitry, or about genetics. Under the DSM-IV, Scully says, too many patients were handed a diagnosis of “not otherwise specified,” a vague term meaning that doctors didn’t have a disorder to fit the symptoms at hand.
The task force hopes that will not be a problem with the DSM-5. “Altogether, we have about 157 specific mental disorders,” Regier says of this manual. “That represents a total of 15 new, and we deleted two.” In addition, the task force took 50 existing diagnoses and collapsed them into 22. Total, there are actually fewer diagnoses than there were in the DSM-IV, he says. “But there is an enormous amount of movement.”
- The DSM: Psychiatry’s Deadliest Scam (voiceofaustralians.wordpress.com)
- Ian Hacking: Who needs the DSM? (lrb.co.uk)
- DSM5 – Changing the Playing Field for Cognitive Diagnosis Saginaw, Michigan (jerryreiflawyer.com)
- Gotta’ love the DSM-5 – NOT? (addandsomuchmore.com)
- Living in America will drive you insane – literally (salon.com)
- Is America a Nation of Java Junkies? (candidaabrahamson.wordpress.com)
- Nimh (lynndllcurtis.wordpress.com)
- New DSM 5 impacts on Veterans who have PTSD (fggam.org)
- Discussion Questions Post (emilypeterson4.wordpress.com)
By George Graham and Owen Flanagan
Even before the much-heralded DSM-5 was released, Thomas Insel the Director of NIMH criticized it for lacking “scientific validity.” In his blog post entitled “Transforming Diagnosis,” Insel admitted that the symptom-based approach of DSM is as good as we can get at present and that it yields “reliability” by disciplining the use of diagnostic terminology among professionals. But (he went on) DSM-5 does not reveal the nature of a mental disorder, which is to be found largely in the head. In an interview with the New York Times, Insel said “his goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.” At the same time, Insel has announced a new initiative called Research Domain Criteria Project (RDoC) at NIMH to develop a new nosology that eventually will replace DSM categories. He writes that this program began with a number of assumptions, two of which are:
- “A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories.”
- “Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior.”
Insel sells RDoC as a replacement of DSM on grounds that “patients with mental disorders deserve better.”
No doubt, patients deserve the best. But is RDoC really the direction in which psychiatry and mental health medicine ought to go? Does a nosology that explicitly pre-privileges the brain and genetics and that begins with the assumption that mental disorders are brain disorders start from a reasonable assumption? Or is this more likely an empirically contentious, discipline non-neutral position about the nature of mental disorders?
Sometimes scientists believe that mental disorders are based in the brain. They don’t recognize that just because a disorder necessarily involves the brain doesn’t mean that it is of the brain (viz. a brain disorder). Consider: One of the reinforcement schedules that is responsible for much human and non-human animal learning is the so-called variable ratio schedule of reinforcement, in which reinforcement is delivered occasionally and unpredictably. It is a powerful schedule for the acquisition of new behavior and well-suited for creatures like us who often must persist in trying to satisfy needs in the face of possibilities of protracted failure. However, when pursued in certain environments, the schedule can lead to gambling addictions and to other patterns of imprudence that qualify as disorders. The brain contains a capacity to squander a family’s resources on a final trifecta.
To get a gambling addict to disengage from a harmful schedule of reinforcement at race tracks or casinos you don’t need to fix the brain. It is not broken. It is behaving as it should from a biological point of view. Indeed, to redesign the brain so that it makes gambling addictions impossible would be a huge mistake.
Our proposal is this: In any particular case of mental illness, even a kind or type of mental illness, the brain may not be at fault. As a brain, it may be in perfectly good working order.
To be sure, we all wish for superior psychiatric diagnostic labels for mental illnesses and for the explanation of the onset and course of illness. Certainly none of us wishes to strip reference to the brain and biological science of an important role in our understanding of mental illness. We need help from brain science for much that we want to know about a disorder. But we need other disciplines as well.
The best picture of a mental illness is not likely to be found in a single, precise, biologically privileged ‘frame’ (viz. a biological marker). The best picture is more likely to be found in the overall manner of organizing the most useful perspectives about an illness that we have or otherwise achieve. Perspectival multiplicity, when properly channeled and evidentially controlled, is often not just the best but the only way in which to understand a phenomenon. Imagine, for example, trying to understand a soccer or tennis match just by deploying the physics of space, time, and motion. It just cannot be done. We need references to human psychology, history, and cultural context.
Ironically, despite his impatience with DSM-5, both DSM-5 and Insel’s aspirational RDoC share one methodological prejudice in common. Both disfavor etiology or history and context in defining mental disorders. In DSM’s case, present symptom clusters are placeholders for eventual filling in by something like RDoC’s neurobiological markers supplemented perhaps by genetic markers. In both DSM and RDoC, mental disorders are conceived exclusively in synchronic or present-tense terms, notdiachronically as complex social-emotional-behavioral syndromes with complex histories and long backtracking arms.
To see where and why non-brain science is important to our understanding of mental illness, we need to assemble a number of points that cannot be assembled here. Mental illness will not be understood by those who live in disconnected sets of scientific rooms or aspire to a single pre-determined resting place of theory.
George Graham is the co-editor of The Oxford Handbook of Philosophy and Psychiatry with KWM Fulford, Martin Davies, Richard Gipps, John Sadler, Giovanni Stanghellini, and Tim Thornton. He is a former president of the Society for Philosophy and Psychiatry, and teaches philosophy at Georgia State, having taught at Alabama-Birmingham and Wake Forest. Owen Flanagan is also a former president of the Society for Philosophy and Psychiatry, and teaches philosophy at Duke, having taught at Wellesley.
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Image credit: Woman losing at roulette table in casino. © monkeybusinessimages via iStockphoto.
- Psychiatry and the brain (oup.com)
Livingonborderlines · 35 like this
- YOU CAN’T EXPLAIN OUR FEARS, OUR RAGE AND OUR DESPAIR WITH NEUROTRANSMITTERS AND SYNAPSES. WE CAN’T PULL OUT THE LATEST EDITION OF THE DSM-V AND POINT TO A DESCRIPTION THAT INVOKES SYMPATHY, THE VERY DEFINITION OF OUR ILLNESS FURTHER INCRIMINATES US. WE HAVE “INTENSE EMOTIONAL OUTBURSTS.” WE HAVE “UNSTABLE RELATIONSHIPS.” WE ARE NOTORIOUSLY “PROMISCUOUS.” WE ARE IMPULSIVE. WE ARE DEMANDING. WE DRIVE TOO FAST. WE ARE LOUD. WE ARE ANGRY. WE ARE AGGRESSIVE. WE WANT YOUR ATTENTION.
- THERAPISTS AND PSYCHIATRISTS DO NOT UNDERSTAND US. WE DON’T BEHAVE THE WAY THEY EXPECT US TO. WE DON’T SIT ON THEIR SOFT LEATHER COUCHES, DESCRIBING OURSELVES AS THE PASSIVE, HELPLESS VICTIMS THEY’RE USED TO SEEING. WE AREN’T THE GIRLS HIDING IN OUR CLOSETS ALL DAY, WE ARE THE WOMEN WHO WRITE OUR RAGE ON THE WALLS. WE ARE NOT SITTING BY THE PHONE WAITING, WE ARE SCREAMING AT YOU IN THE PARKING LOT AT 2:00 AM. WE DON’T STAY IN OUR HOSPITAL BEDS CRYING, ZONED OUT ON AMBIEN, WE ARE THE WOMAN AT THE FRONT DESK CUSSING OUT THE NURSE. WE ARE THE CRAZY BITCHES THAT MEN SPEAK OF.WE ARE TRAUMATIZED. WE ARE ABUSED. WE HAVE DARK PASTS AND WE DON’T LET GO AND WE DON’T HIDE OUR SCARS. SOME OF US EVEN WEAR THEM ON OUR ARMS. UNLIKE MANY OTHER WOMEN WHO HAVE SUFFERED TRAUMAS, WE DON’T GO TO OUR SADNESS, WE GO TO OUR ANGER.
OUR FRUSTRATION IS INTENSE. IN THERAPY WE ARE TAUGHT TO CONTROL OUR “RESPONSES” TO OUR RIGHTEOUS ANGER. WE ARE TOLD THAT OUR REACTIONS ARE “EXTREME.” WE TRY NOT TO “DOMINATE THE CONVERSATION” BUT WE WANT IS TO BE HEARD. WE ARE TIRED OF BEING TOLD TO CONTROL OUR TONE, THE VOLUME OF OUR VOICES. OUR RAGE IS RAW AND WE KNOW THAT IT IS REAL.
Rage is our comfort zone, the emotions we are not allowed to express “in public”. WE HAVE LEARNED HOW TO TAKE THAT RAGE AND PUT INTO OUR OURSELVES.
- WE HAVE HURT OURSELVES SO MUCH MORE THAN WE WILL EVER HURT YOU. OUR RAGE IS OUR DRUG ABUSE AND OUR BINGE DRINKING. OUR RAGE IS OUR OVERDOSES AND OUR ALCOHOL POISONING. OUR RAGE IS OUR CUTTING. OUR RAGE IS OUR SHATTERED MIRRORS, OUR RAGE IS THE HOLES WE PUNCHED IN OUR OWN WALLS. OUR RAGE IS OUR BROKEN ROMANCES; OUR RAGE IS OUR BROKEN DREAMS.
But we are more than what people see of us. Behind our HOUR-GLASS FIGURES, OUR SULTRY SWAGGER THAT ATTRACTS MEN’S STARES, IS THE GIRL WHO NO ONE ASKED TO PROM. UNDERNEATH OUR TUBE TOPS AND OUR MINISKIRTS IS A BODY THAT WAS ABUSED. INSIDE THE TOPLESS PICTURE WE SENT YOU, IS THE MESSAGE THAT WE WANT TO BE LOVED. THE SUBTITLES THAT YOU CAN’T READ, TO OUR SASSY MOUTHY COMMENTS, IS OUR FEAR THAT WE AREN’T GOOD ENOUGH FOR YOU. NEXT TO THE SMASHED BEER BOTTLES, IS OUR FRUSTRATION THAT WE DISAPPOINTED YOU. AGAIN. OUR DESPAIR OVER US ROLLS LIKE LIQUID OVER CONCRETE, WASHING AWAY WITH THE RAIN.
WHAT YOU DON’T KNOW IS THAT WE INHALE OUR SHAME WITH THE SMOKE OF OUR CIGARETTES. OF ALL THE “RECKLESS” ACTIONS WE SO RIGHTEOUSLY DEFEND, WE ARE ASHAMED OF EVERY LAST ONE OF THEM. WE ARE ASHAMED OF ALMOST EVERYTHING WE DO AND ALMOST EVERYTHING WE DON’T DO. ALL OF THOSE ANGRY TEXTS WE SENT YOU IN THE MIDDLE OF THE NIGHT, EVERY SINGLE ONE OF THEM READS, “PLEASE DON’T LEAVE.” WE HATE THE STIGMA OF OUR ILLNESS MORE THAT YOU CAN EVER IMAGINE, BUT WE’RE HERE IN THIS CAMP FOR A REASON. AT SOME POINT IN OUR LIVES WE WERE LEFT ALONE. YES, SOME WOMEN IN OUR SAME SHOES WOULD HAVE BEEN ABLE TO “HANDLE IT” OR “MOVE ON.” BUT WE DIDN’T. BECAUSE WE COULDN’T.
This is all I have left to say: Please don`t leave us. Please don`t leave us alone again.
- “i Have Borderline Personality Disorder and I’m Proud of It!” (makebpdstigmafree.wordpress.com)
- The Stigma that Borderline Personality Disorders sufferers Attract (takingbackthereins.wordpress.com)
- The 3 Most Commonly Diagnosed Mental Disorders (fool.com)
- Mental Disorder – a Clinical Illness, Not a Personal Flaw (icontrolmyhealth.wordpress.com)
- Personal Experience in Labeling Borderline Personality Disorder (brainblogger.com)
- Breaking the Silence of Stigma: Pride in Madness (bipolarforlife.me)