The Insanity of the Defense - Mental Disease Overview

Written by Dr. Sam Vaknin

The members of the functional school regard mental health disorders as perturbations in the proper, statistically "normal", behaviours and manifestations of "healthy" individuals, or as dysfunctions.

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The "sick" individual - ill at ease with himself (ego-dystonic) or making others unhappy (deviant) - is "mended" when rendered functional again by the prevailing standards of his social and cultural frame of reference.

In a way, the three schools are akin to the trio of blind men who render disparate descriptions of the very same elephant. Still, they share not only their subject matter - but, to a counter intuitively large degree, a faulty methodology.

As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, notes in his article "The Lying Truths of Psychiatry", mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or failure of treatment modalities.

This form of "reverse engineering" of scientific models is not unknown in other fields of science, nor is it unacceptable if the experiments meet the criteria of the scientific method. The theory must be all-inclusive (anamnetic), consistent, falsifiable, logically compatible, monovalent, and parsimonious. Psychological "theories" - even the "medical" ones (the role of serotonin and dopamine in mood disorders, for instance) - are usually none of these things.

The outcome is a bewildering array of ever-shifting mental health "diagnoses" expressly centred around Western civilisation and its standards (example: the ethical objection to suicide). Neurosis, a historically fundamental "condition" vanished after 1980. Homosexuality, according to the American Psychiatric Association, was a pathology prior to 1973. Seven years later, narcissism was declared a "personality disorder", almost seven decades after it was first described by Freud.

III. Personality Disorders

Indeed, personality disorders are an excellent example of the kaleidoscopic landscape of "objective" psychiatry.

The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952, in the first edition of the DSM.

The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.

The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.

The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.

The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses).

The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders.

A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.

Numerous personality disorders are "not otherwise specified" - a catchall, basket "category".

Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal).

The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:

"An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another" (p.689)