A critical perspective on psychological diagnoses

We all know the story of the frog wanting the princess to kiss him as he will become a prince after the kiss. Either a frog or a prince. Nothing in between, depending on the kiss.

As human beings, we always tend to put ideas, thoughts, concepts, and even human behaviour into boxes. We just love diagnoses.

Everything or everyone outside our box of reality needs to be diagnosed. By studying especially people who are unusually talented are being labelled, who may tend to do and understand things differently than you do, must be diagnosed as weird, alternative, or whatever label you want to attach to it.

Against diagnoses

I have written this article in 2014 with the publishing of the long-awaited and controversial DSM 5. It is now the year 2023, and the DSM-5 has just been replaced with the DSM-5R (Revised) which in turn, is changing the landscapes of psychological diagnoses once again.

The DSM-5 (which is the abbreviation for the Diagnostic and Statistical Manual of Mental Disorders, Edition 5) is the bible of psychiatrists, medical doctors, and psychologists’ diagnoses of mental disorders and is published by the APA (American Psychological Association). Since 1953, several attempts have been made to diagnose and place people in categories of disorders.

Since 1952 to this day, the DSM has attempted to place people in a box and the boxes have been constantly changed and adapted in an attempt to classify the complexity of the human being into categories of pathology. The more boxes, the more chaotic it became. In 1952, there were about 106 boxes. In 1968, The DSM-II was released with 182 boxes. Homosexuality was described as a disturbance in the DSM-II, but in 1980 it was voted, with a small majority, that it is indeed not a disturbance and has been dropped in the new DSM-III. The number of disorders since the DSM-II was published, only became more and more. There also happened to be a discrepancy between votes on the difference between diagnoses in the USA and the rest of the world. Meanwhile, the boxes in the DSM-III have grown to 265. During the course of 1987, the boxes in the DSM-III have grown to 292.

The DSM-IV made its appearance with 297 (boxes) disorders. Admittedly just five more, but the number was increasing.

To give you an idea (a selection of the DSM-5)

(You might like to read this passage only if you are critical and wonder what I’m referring to. Otherwise, you can skip to the next heading).

With the introduction of the DSM-5, the Roman numerals were also changed, for unknown reasons.

One of the most controversial issues of the DSM-5 was that a diagnosis such as bereavement no longer exists. Although the symptoms of bereavement and grief are exactly as those of depression, there is a distinction in the DSM-IV, as the loss of someone close is seen as a natural grieving process. The DSM-5 considers it as a component of depression, and as a result, you may now rather be chemically treated instead of allowed to go through the natural grieving process that every individual must go through as death is an inevitable part of life.

The new classification of post-traumatic stress disorder (PTSD) is, as I see it, also going to be subjected to attack. PTSD is a condition that arises after exposure to a traumatic event where your life or physical integrity was threatened, or where you witnessed an event where someone else’s life or physical integrity was threatened. According to the DSM-IV, the individual’s response to such an event is one of helplessness, fear, and a sense of horror. The mentioned reaction has now disappeared from the DSM-5. It may seem that someone who has been diagnosed with PTSD until now is faithfully going to receive their medication and therapy until they suddenly no longer suffer from PTSD. Or worse yet: someone might suddenly have PTSD now, simply because the criteria are changing.

And now, ladies and gentlemen, we also have Disruptive Mood Dysregulation (DMD). Children who throw temper tantrums are no longer naughty but have a psychological challenge. The so-called naughty child just wants to be heard or is frustrated about their schoolbag going missing, to be further pumped full of medication. Just because there is now such a diagnosis.

Binge Eating is another new disorder. If you eat yourself, more than 12 times, in three months, into another planet, you now have a problem. No one tells us how the APA came about this and how much you should eat during a binge period. It is also not clear whether it can be defined as an independent diagnosis or whether Binge Eating is a symptom of another disturbance. However, overeating can also be the result of a depressive episode (according to the criteria in the DSM-IV).

It should not come as a surprise that there were little to no changes made in the diagnosis of Major Depression Disorder (MDD) and General Anxiety Disorder (GAD). These two disorders are by far the most common disorders in the psychiatric context. It is argued that these two disturbances have been so well researched and pharmaceutical companies have already invested a lot of money into it, that it should be left as is.

It still remains a mystery to try to discover who decided how many of the criteria one should meet to receive a diagnosis. There are in the old DSM-IV nine criteria for depression. If you meet more than half of any of the mentioned criteria, you will receive a diagnosis. It is unclear about the research methodology being used to determine what and how many criteria one has to meet to be diagnosed. You may, for instance, feel incredibly depressed (one of the criteria for depression) but you are not meeting any of the other criteria – thus, you are then considered not to be depressed.

As mentioned before, the APA could not agree on how many symptoms it would now take to determine a disturbance. However, the law of averages had the upper hand. It looks like the old problem with democracy – half plus one will determine who will govern. We would have to wait to see how the DSM-5 is going to bridge this dilemma.

Our best friend, the infamous Bipolar disorder (better known as Manic Depressive Disorder) is still with us. This will now be called Bipolar spectrum disorder (BSD). The difference between Bipolar 1 and Bipolar 2 disappeared and rather the severity of BSD will be diagnosed. Previously Bipolar 1 was seen as a softer Bipolar and accordingly referred to as Soft Bipolar. Bipolar 2 was seen to be the more serious one, with more intense symptoms and a longer duration.

Asperger syndrome also disappeared. These people will now be diagnosed with Autism Spectrum disorder (ASD). Autism, as a diagnosis, now also disappears as a disturbance and will become bustled into the category ASD.

Addiction is another taffy. Is the person hooked on or just dependent on certain substances? Is addiction actually caused by the ingredients contained in the substance, or is it caused by the dopamine released in the brain? Gambling, just like drugs is now called an addiction in the DSM-5, where there is no substance involved. Yet the symptoms are the same. What the heck is the difference between a behavioural addiction (BA) and a chemical addiction (CA)? Even welfare work, just like gambling, alcohol, and drugs can be equally addictive since it releases dopamine in the brain. It can even become addictive to allow another car on the highway to pass you! Is it about the substance or is it about the feeling it’s causing in the person? Is withdrawal really physical or might it be emotional?

What is psychosis? Is it something like schizophrenia, something that is not meeting our frame of reference? Or might it be that it is not meeting the APA’s ideas of whatever is normal? What if the schizophrenics who claim that they are Jesus, Muhammad, Buddha, or whoever is truly the One? We know hopelessly too little of something like the so-called schizophrenia. We may even ask ourselves what reality really is.

Say welcome to the newcomer, Excoriasis (to scratch skin from your body), but where are our old friends, Nail Biting or Teeth Clenching now? Nobody is ever asking whether it may just be symptoms of other disturbances. We do not yet know where it is going to fit in, but I have an idea that it is just another box to categorise the individual by.

Another new debutant is Hoarding Disorder (HD). Although HD has never been recorded in the DSM previously, it is now regarded as a form of Obsessive compulsive disorder (OCD). My friend Carl is a typical hoarder. He recently built a beautiful gate for a client of his, using material he was hoarding on his premises. He ensures that he hoards his belongings away from his wife’s sight. Carl does not know it yet, but he might now be classified psychologically healthy. However, one morning he might wake up being diagnosed with OCD and will probably have to go on medication. For the APA has decided so.

The new DSM even contains something like an Olfactory reference syndrome (ORS), which is the fear of smelling bad.

So, Mister APA, we are waiting for more weird and wacky diagnoses to come.

What is a psychological disorder really?

As human-being, we love putting things and people into boxes. We, however, don’t really get answers about what the nature of these boxes really is. Is it really necessary for us to be stuck in the pathology model? Should psychologists, cell phones in the hand, walk around in hospitals, like doctors in white jackets, lookin
g for pathology to treat their suicide crises? May it be that threads of suicide may perhaps be more of a choice than a crisis? Carl’s issue leaves the question of what a psychological disorder really is.

Does the boy who forgot where he left his bookcase have a challenge? Does Daantjie Dynamite have a problem because he can focus well enough to win a TV quiz (and win quite a few rands in the process too)? Is Oscar Pistorius truly guilty, or does he only have PTSD?

Questions can also be asked about culture, racial, and gender differences. Is something that is regarded in the US as a disturbance, necessarily a disturbance in other cultures as well? For example, schizophrenia will now be renamed as Dopamine regulation disorder (DRD). In Japan, however, this disorder will be called Integration disorder (ID). This holds the implication that the Japanese would not refer to it as a chemical imbalance, but simply as psychological issues.

There is a need to understand each other, as well as different cultures better. Western people may regard slaughtering a cow during the funeral of someone as a bit weird. Even Lobola may be considered strange, even pathological by some who don’t understand the custom.

Currently, Western culture does not really comprehend how other cultures understand, deal and resolve challenges. We need to open ourselves up and try to understand other cultures in this regard, before judging them as abnormal.

Does that mean that the rest of the world, with their own cultural differences, must see and accept the DSM as a kind of Holy Scripture?

According to the DSM-IV, a problem can only be a problem when it negatively affects your work, social, or any other area of functioning. A disorder may also be a problem when it affects other people negatively. Could the problem or the challenge perhaps be the other person’s problem? Precisely what the French philosopher, Jean-Paul Sartre said when he proclaimed: hell is actually other people. Feel free to read my article named: Hell is other people, here on my website, under Food for thought. Or could the problem just be a challenge?

It might be helpful to regard any psychological challenge to degrees of seriousness, namely: mild, moderate, and severe. It may serve as a solution. Whatever the criteria may be, I foresee that there will soon be a few upgrades from the DSM-5 to try to overcome challenges like the above mentioned.

As you may have noticed throughout this website – I prefer to use the word challenge instead of problem. Nobody ever has a problem, but they always have challenges.

The above-mentioned is forcing questions about the relevance of the DSM whatsoever. However, the issue of personality disorders must be discussed, before we can commence.

Personality Disorders

I foresee that the so-called personality disorders are increasingly going to become a thorn in the flesh of practitioners, and that they might even disappear from the DSM.

What is a personality disorder anyway? What are the criteria by which it is measured if it is possible to measure it at all? Is it possible that anyone can be so broken that recovery is impossible?

Is anyone doomed forever to be a Psychopath (Antisocial Personality disorder – APD) or a Narcissist (NPD)? What is personality anyway? How do we define it? Does it need to be redefined? Why is it that certain personality disorders such as Dependant personality disorder (DPD) are no longer contained in the DSM? It appears that the reason for these anomalies is merely just a lack of research and that no one is interested in researching these particular disturbances. Are you perhaps just as frustrated with the abbreviations as I am? What goes where now? How did it happen that histrionic personality Disorder is no longer part of personality disorders? We now, long after her death, owe Marilyn Monroe an apology, since we, with the support of the mighty APA, decided that she was being hysterical without any deeper content. RIP Marilyn, there was nothing wrong with you. Our sincere apology. We might diagnose you again later if someone is interested in doing further research on this topic. For now, you are not completely forgotten, but watch this space. We still think you were crazy, and we have kept a trash category just in case. Sorry, Marilyn, psychology could not see you for who you were. You just had to fit into our categories.

Fortunately, there has been enough research done on Borderline Personality disorder (BPD) that left Princess Diana (who had to kiss the frog on the balcony of Buckingham Palace) long after her death just like that, being diagnosed, irrespective of her circumstances.

Is it possible that a person can be doomed to be disturbed? Or is the APA trying to soften the so-called personality disorders with their criteria of a mild, moderate, or severe degree, in trying to sidestep this problem? We might realise that the person with an Obsessive Compulsive personality disorder (OCP) might just perhaps be an Obsessive compulsive disorder (OCD) on steroids. People with Borderline personality disorder (BPD) with their intense fear of so-called rejection, might just be a severe degree of anxiety.

The disturbances that got away

Those people who hurt themselves, not necessarily trying to kill themselves, as well as the sex addicts, are exonerated. Parents who alienated their children are also discharged. Free are those who are addicted to internet games. They are free for now, due to the lack of research and may be charged again in the foreseeable future. We might even get new diagnoses such as Facebook addiction (FAD), Farmville addiction (FVA), Shop trolley rage (STR), Restaurant rage (RRD), and even much more. Even Marilyn Monroe, after further research, can be declared crazy again.

Is a new paradigm due?

It might be time to move away from the process of boxing people. We should rather address the boxes and see people as individuals in their own right.

These diagnoses are becoming more and more complex. Every now and then, new boxes and new diagnoses appear and the old boxes just disappear.

The DSM system still presupposes that certain people are not well and that these diseases should be fought. It might be time for us to move away from the idea of disorders and boxes, but what are we going to replace them with? The absence of depression is not the same as the presence of happiness, positive emotions, and meaning in life. These issues are not being addressed in the DSM-5.

The appearance of the new DSM-5 reached us during a period when the so-called positive psychology (with many branches and names) is gaining more and more field. This thinking presupposes that there is nothing wrong with anybody. You are created with everything you need to be successful, is the motto according to this thinking. It rather asks what it is that makes us feel good, what is making us function, and what is flourishing us. This does not mean that happiness is the absence of depression, but positive psychology is a new independent science. It rather focuses on identifying the positive in man to be able to work through the negatives.

It is my dream for the APA to rather compile a guide with diagnostic criteria for Savouring, Gratitude, Mindfulness, Optimism, Resilience, Joy of Living, and so much more.

Instead of labelling someone, we can rather dig out the positive qualities that are buried under the bushel and use them to our advantage. When you build and focus on the positives in life, the negatives might just disappear.

The focus, therefore, should not be on what is wrong with man, but rather on that which is good with man. We can rather ask questions about what the positive intention behind behaviour was, rather than condemn the behaviour itself. We, as human beings, may not have to judge, but should rather look for the positive intention behind the behaviour of people, also regarding people currently in the news. They might have done what they thought to be best with the resources and information they had available at the time.

We now start to realise that we are actually all still princes – all created perfect in our own way.

When we understand this, we can make the world a better place. Creating a better life.

Postscript

I really don’t know what the difference between frogs and princesses are anymore. Whether the princess who turned a frog into a prince was more of a frog than the frog could ever be or perhaps more of a prince than a prince could ever be.

The final choice still lies with you and you alone. Hell is not other people, except if you allow them to make it your hell by placing yourself in one of these many boxes.

At the end of the day the decision to be a frog or a prince depends on you, and you alone.

References

• Burke, A (prof). Paper delivered on 16 March 2013: DSM-5: Back to the future. South African Society for Clinical Hypnosis (SASCH), Pretoria.
• Harris, Jorgan. 2011. NLP – Ontgin die briljantheid in jou. Griffel Media. Cape Town.
• Bullyonline.org
• Wilkipedia.com
• Psychsystems.net
• Abcnews.go.com