Sun, Jun 27, 2010 - Page 9 News List

DSM seeks to define normal eccentricity as mental disorder

By Jerome Wakefield

The American Psychiatric Association recently proposed changes to its official diagnostic manual the Diagnostic and Statistical Manual of Mental Disorders (DSM) — often called the “bible of psychiatry” — that may discredit psychiatric diagnosis more than improve it. The DSM specifies the symptoms by which every mental disorder is diagnosed, in effect defining what is considered psychologically normal and abnormal in the US — and, increasingly, for much of the rest of the world as well.

Revising the DSM’s diagnostic criteria for the upcoming fifth edition (“DSM-5”) is a heavy responsibility. Draw the line between normality and disorder too broadly, and individuals may suffer incorrect diagnoses and undergo needless and potentially harmful treatment. Indeed, the DSM’s history reveals many such errors of over-inclusiveness.

But if the line is drawn too narrowly, individuals may not get the help they need. Although psychiatrists tend to worry more about identifying patients in need of help and less about eliminating normal eccentricity and distress from diagnosis, it is crucial in any society that respects human variation and encourages individual moral responsibility to distinguish normal suffering and eccentricity from mental disorder.

These are delicate issues of conceptual analysis. Yet the psychiatrists who formulated the DSM-5’s proposed changes are not trained in conceptual analysis, and, though amply forewarned, they have addressed the normal-versus-disordered issue in an unsystematic, ad hoc manner. The result is a form of conceptual malpractice: intellectual negligence resulting in the formulation of invalid diagnostic criteria that will misdiagnose normal individuals as disordered.

Consider the following proposed new disorders:

One, binge eating disorder. If you overeat once a week for three months, lacking self-control and experiencing over-fullness afterward, and are distressed, embarrassed and disgusted with yourself, you are diagnosable. Apparently, people who feel bad about not being in full control of their eating when confronted by weekend buffet-style feasts are disordered.


Two, hoarding disorder. If you resist discarding possessions that others (a spouse, say or a clinician) find of limited value, and consequently clutter your living space and you are distressed about this or are creating what others consider an unsafe environment, you are diagnosable. This category will be welcomed by neatniks irritated by acquisitive partners.

Three, hypersexual disorder. If you are highly sexual for six months in a way that feels uncontrolled and becomes distressing, and use sexuality to relieve feelings of stress and boredom or without consideration of the emotional effect on others (formerly known as being a “cad”), you are diagnosable. This disorder presumes that using sex to relieve unhappiness, and feeling guilty about it, is also diagnosable.

Other proposed DSM-5 changes open the door to future abuses. “Pathological gambling” would be placed in a new super-category of “behavioral addictions,” opening the way for “Internet addiction” and many other behaviors to be deemed pathological.

Likewise, loose or quirky thinking that is not now a disorder but indicates an increased risk of developing a psychotic disorder would be classified as a “psychotic risk disorder.” Those diagnosed with this condition would be more likely to be treated with potent drugs, though most never develop a psychotic disorder — setting a precedent for confusing risk factors with actual disorders.

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