Neurophilosophy

In an op-ed from yesterday’s NY Times, Christopher Lane, a professor of English at Northwestern University, argues that shy kids are not mentally ill, and that they shouldn’t be given medication.

The piece brought to mind this critique of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), by L. J. Davis:

Current among the many symptoms of the deranged mind are bad writing (315.2, and its associated symptom, poor handwriting); coffee drinking, including coffee nerves (305.90), bad coffee nerves (292.89), inability to sleep after drinking too much coffee (292.89), and something that probably has something to do with coffee, though the therapist can’t put his finger on it (292.9); shyness (299.80), (also known as Asperger’s Disorder); sleepwalking (307.46); jet lag (307.45); snobbery (301.7, a subset of Antisocial Personality Disorder); and insomnia (307.42); to say nothing of tobacco smoking, which includes both getting hooked (305.10) and going cold turkey (292.0). You were out of your mind the last time you have a nightmare (307.47). Clumsiness is now a mental illness (315.4). So is playing video games (Malingering, V65.2). So is doing just about anything “vigorously.” So, under certain circumstances, is falling asleep at night.

The numbers in brackets are codes for each “disorder”; here is a complete list.

Comments

#1 ebohlman
September 22, 2007

In addition to using inflammatory terms (“deranged mind”), the author fails to understand the basics of differential diagnosis. Many of those diagnoses he cites are there mostly for rule-out purposes. The caffeine-intoxication one is typically cited as ludicrous, but it’s there because some of the symptoms of caffeine intoxication can also be symptoms of something much more serious (additionally, if you’re going to give a benzo to someone with serious caffeine intoxication, you’d better have a diagnosis to justify it).
#2 Benjamin Franz
September 22, 2007

With nothing more than that excerpt, I already know that L. J. Davis is not someone I particularly need to listen to. Asperger’s is not ‘shyness’. It often includes shyness as a symptom. But that is like saying ‘Sore fingers (aka Rheumatoid Arthritis)’.

Asperger’s is disabling. Those who want to lump it as mere ‘difference’ have never had to cope with it in its more severe forms. It pervasively affects a person’s life.

You should also note that L. J. Davis wrote that a mere 5 years after Asperger’s was accepted as a standard diagnosis by the World Health Organization. I’m sure I could find similarly stupidly disparaging statements about a number of other diseases shortly after they were first officially recognized. Idiots abound.
#3 Tom Nichols
September 22, 2007

I don’t know if it should be considered a psychiatric condition (or if those other things should either), but I wish more people would understand how hard it is to be shy. So many people think: quit whining and just get over it. But it is not easy. I still remember one of my elementary school teachers yelling at me to go out and play on the playground during recess, instead of hovering near the school. I’m much better as an adult, but shyness robs people of so many experiences in life.
#4 Caledonian
September 23, 2007

Asperger’s is disabling. Those who want to lump it as mere ‘difference’ have never had to cope with it in its more severe forms.

Those who want to call it a disease have likely never had to acknowledge that the vast majority of defined cases aren’t severe.
#5 David Dufty
September 23, 2007

LJ Davis thinks he’s one of the “hard” scientists, coming in to teach those namby pamby social researchers a lesson. However, what he’s really doing is siding with the anti-science postmodernist perspective that mental illness is a social construct. He should look into a little history to find out who he’s siding with. In my mind, his position is akin to AIDS denialism. DSM-IV has many problems, some quite serious, but none of them are articulated by LJ Davis. Instead, he focuses on problems that don’t exist (like coffee drinking being a disorder). The article deliberately misinterprets and misunderstands the DSM approach in order to pillory it.

His sarcastic dismissal of depression stands forth as the most egregious ignorance. Perhaps he has an alternative explanation for the staggeringly high rate of suicide (otherwise known as death by depression). That’s an empirical fact in need of an explanatory theory. Ockham’s razor rules here: there is currently a high rate of depression, for reasons that are not clear.

On shyness and aspergers, I have not seen such a wilful distortion of an opponent’s position. Shyness and Asperger’s are not the same thing. This is a straw man.
#6 Obdulantist
September 23, 2007

Although I am a hard critic of the DSM and the process that produces it, I have to agree with those saying that Asperger’s and shyness are not the same.

I have a personal stake in this one: One of my nephews, who I often take care of, is an Asperger’s kid. Despite being very bright and getting a lot of support from his family, he has a whole bunch of serious problems, especially with socialising, which have been there since day one. His problems go way, way past mere shyness.

Having said that, the correct classification of Asperger’s is not immediately obvious to me.

As to LJ Davis, while he(?) makes some stupid accusations, some of them are also legit. The DSM is not the most scientific and reliable of documents, and is stuffed full of value laden judgements. The distinction between genuine psychopathology, and merely statistically abnormal (and even socially disruptive) behaviour is not at all clear, and psych has not exactly covered itself in glory over this issue.
#7 ChuckO
September 23, 2007

While I understand the point of the preceding comments, one has to make a distinction between the way things are in principle and the way they are in practice. When properly applied, these diagnostic categories may well be apt. However, they are often misapplied. The most common example of that is in the case of depression. Go to the average physician and tell him or her that you’re feeling down, and you’re quite likely to walk out of the office with a prescription for an anti-depressant. No attempt is made to distinguish between simple unhappiness and depression. An even more egregious example is that of attention-deficit disorder. How many children end up on medication for this condition simply because they are disruptive in class?

My inclination is to believe that many psychiatric conditions are over-diagnosed. Yet another example is the bipolar disorder. In another science blog here, it was stated that about one in twenty-five people suffer from bipolar symptoms. Well, I’ve known a couple of people who truly suffered from bipolar disorder and I don’t believe that 4% of us suffer from it. There may be those who have tendencies in that direction, but are these people suffering from a pathology that demands treatment?
#8 Benjamin Franz
September 23, 2007

Caledonian: Those who want to call it a disease have likely never had to acknowledge that the vast majority of defined cases aren’t severe.

You have statistics to back that up?

Regardless, it reminds me of the efforts by some in the deaf community to deny that deafness is a disease/illness/disability. Ditto for dwarfism. To the point where some parents have actually made the attempt to misuse genetic screening to ensure the birth of a disabled child.

Because it is just “different”: Not a disease or anything.

It is still bullshit by people who don’t want to be labelled disabled. Don’t want to be told they are NOT completely healthy. Want to be told a nice warm fuzzy fairytale.
#9 Odile
September 23, 2007

I couldn’t help thinking: ‘and to label all behavior as deranged is a disorder…’
I agree that there is a relationship between DSM and reality: disorders are linked to experiences in the real world, and when you have Asperger, you have it in different situations and different cultures, at different ages.
I also can see the point critiques of DSM make as to how it developped from observations, maybe arbitrary. What is generally called ‘normal’ may change over time.
#10 llewelly
September 23, 2007

So many people think: quit whining and just get over it.

It’s very popular thing to say, but there’s never been any evidence that telling people to ‘get over it’ is correlated with any kind of improvement.
#11 David Dufty
September 23, 2007

What is generally called ‘normal’ may change over time.

That rather innocuous statement (after all, who could disagree?) is one of the pillars of the anti-psychiatry movement. The weaknesses in the DSM are also used to bolster the case that mental disorders are an invention of the medical profession.
It’s true that “normal” changes over time, but normality is not completely arbitrary. There are diseases and conditions that impair functioning, or bring it to a halt.
Sure, there have been some mistakes that in hindsight are laughable (e.g., the much used example of homosexuality once being a disorder). However this is in large part due to the fact that psychology and psychiatry are very new, the whole area is at the frontier of research and is pretty poorly understood.
One of the sins of DSM is attempting to jump the starting gun, and create well-defined syndromes and their definitions, when the reality is we’re still figuring out the typology of the whole thing. It’s true, this has led to a certain amount of reification: creation of disorders that might not exist at all. Yes, we can make fun of it, and yes, it’s right to be critical. However, to use that to attack the whole enterprise is dangerous, and will hold back an important and emerging branch of medicine by years or more.
#12 Odile
September 24, 2007

David,
I agree with you. Psychology and Psychiatry are a relief to many people who are at risk of not being understood and at risk of maltreatment.

The definition of disorders is a developping science that needs to reflect on itself, but also needs to exist. One of my teachers pleaded that every psychologist needs to be a researcher. Especially the ones telling us what to do.

What I’m suggesting is that normal people of today may benefit from Psychology and/or Psychiatry too.

Is the use of irony the same as ridicule? in that case, I apologize.
#13 Obdulantist
September 24, 2007

David Duffy: Good post. But the problems with the DSM and psych go past that. An awful lot of the diagnostic process and criteria are far too subjective and unverifiable, and that opens the door to all sorts of incompetence and even quite nasty personal prejudices and control lust in the diagnostician. Even getting diagnostic consistency between diagnosticians doesn’t solve the problem, all it might be doing is standardising and entrenching the subjective diagnostic bias.
#14 Odile
September 24, 2007

Obdulantrist,

What you say shows that the discipline of testing shouldn’t be done by just anyone. I can agree to this. Surely someone has written a list of measures how to prevent misdiagnosis.

I think there might be some factors that prevent the mistake of misdiagnosis. One is excellent training, another is specialisation in diagnosis, also a correct mindset and attitude of the one who does the diagnosis.
I would like a diagnostic to score very high on logical thinking.

But another problem might be that DSM is a theory. It has a strong empirical basis, we shouldn’t want to dismiss it, but we might draw other conclusions over the same facts somewhere in the future.

I’m pleased that this does happen and that associations do reflect upon themselves and listen to criticism.
#15 Caledonian
September 24, 2007

You have statistics to back that up?

No, just the clinical criteria for the condition. But that would require you to apply reason, which for obvious reasons you are loathe to attempt.
#16 Obdulantist
September 24, 2007

What you say shows that the discipline of testing shouldn’t be done by just anyone.

No, I am saying that even among the best trained, most experienced, and best intentioned experts there are substantial discrepancies. It is due to the inherently subjective nature of a lot of these diagnostic categories.

You want to see a field completely riddled with all these problems, go check out psychosomatics.

I have recently read an independent outcomes assessment report of a major program (many hundreds of patients) that reported a 9 fold differential in the diagnostic rate of somatoform disorder, 3 fold of depressive disorder, and 2.5 fold of anxiety disorder, within the same cultural setting and geographical area, by top level experts, in tertiary clinical units. Do you think these kind of differentials in diagnostic rates in the same patient population would be acceptable for appendicitis, malaria, fractured femur, etc.?

also a correct mindset and attitude of the one who does the diagnosis.

How does one objectively determine such a ‘correct’ attitude and mindset? That is a real minefield you are walking into there, stuffed full of value judgements.
#17 beajerry
September 25, 2007

I’m sure Garrison Keillor would take issue with shyness not being normal.

PowderedMilk Biscuits anyone?
#18 David Harmon
September 25, 2007

The DSM is certainly incomplete and far from perfect; Dr. Caplan (They Say You’re Crazy) among others has discussed the problems with the creation of various diagnoses. To try and dismiss the whole thing based on its flaws is blind absolutism. Yes, psychology is a new field, will working on both typology and theory. But just because it doesn’t know everything absolutely and certainly, does not in any way imply that it knows nothing.

“Making the perfect the enemy of the good” is a classic tactic for undercutting and damaging science, or rational thought in general. Indeed, the arguments based on that tactic can often be traced right back to the “usual suspects” in the current anti-science campaigns.

After all, there’s plenty of religious and political sorts who will happily tell you that they are absolutely certain of their knowledge, and that anyone who isn’t, obviously lacks the Faith needed to accept the Absolute Truth. We know where that leads….