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Australian philosopher, literary critic, legal scholar, and professional writer. Based in Newcastle, NSW. Author of FREEDOM OF RELIGION AND THE SECULAR STATE (2012), HUMANITY ENHANCED (2014), and THE MYSTERY OF MORAL AUTHORITY (2016).

Thursday, May 17, 2012

Crazy DSM guidelines on alcoholism

I should make nannying a theme of this blog. I get fed up with the constant attempts to treat people's legitimate choices as pathological. These proposed, guidelines would reclassify as alcoholics very large numbers of people (especially young people in university or college) who choose to get drunk now and then. Bloody ridiculous!

The longer term implication of these kinds of changes to diagnostic manuals could be very illiberal. Potentially, many choices could come to be regarded as illegitimate on the basis that someone making those choices must suffer from a mental disorder. A diagnostic manual of mental disorders can end up being used to do an end run around people's political freedom - all sorts of behavioral choices could be stigmatised as revealing mental disorder. It's not as if we lack historical experience with this. Think of how homosexuality has been treated in the past, not to mention any interest in sex on the part of women. If we're not careful "mental disorders" can become, as they sometimes have become in the past, mere political constructs.

How, exactly, we fight back against ubiquitous paternalism by the medical profession and others I don't know. But we can at least protest.


The Uncredible Hallq said...

Though this is only incrementally worse than the current criteria, which would seem to classify some 40% of college students as "alcohol abusers."

Russell Blackford said...

For the record, middle para added as an edit.

Lee said...

Think bigger: http://www.amazon.com/The-Myth-Mental-Illness-Foundations/dp/0061771228

"By diagnosing unwanted behavior as mental illness, psychiatrists, Szasz argues, absolve individuals of responsibility for their actions and instead blame their alleged illness."

He questions the assumption of a "normal" behavior, and wonders at length at the absence of hard evidence of anything resembling "abnormal". Have you encountered and/or considered the idea that the imprisoning of visionaries like de Sade, or run-of-the-mill discontents throughout history, is as a whole perhaps little more than an engine of social control? His thesis sounds radical, but the more I think about it, the more frustrated are my efforts at discerning a flaw in the reasoning or facts.

I'd be interested in hearing from a philosopher on this, if you have the time.

Russell Blackford said...

Hi, Lee. Well, Szasz's view is not really a new one - and really the whole of notion of normal human functioning is a very contested one even when we're dealing with physical diseases. With "mental disorders" it's that's much more difficult again.

I'll talk a bit further about this in the human enhancement book (forthcoming from MIT Press some time in the next year or two!), but meanwhile there's quite a body of literature on it.

There must surely be limits, though - some people really are incompetent to understand the reality around them, for example. Still, one thing that's fairly clear to me is that documents such as the DSM are politicised ... and their classifications don't simply cut nature at the joints.

Anonymous said...

Those Nazis!

Verbose Stoic said...

The other day I had TVO running and there was a lecturer who was talking about this sort of thing was far too common in DSM V. However, the examples I heard him use were depression and binge eating. He said that for depression it tended to not take causes into account all that well -- I think it was in that lecture that he commented that being a Leafs fan and having them not make the playoffs would make him depressed, but that's not a problem -- and especially that binge eating's guidelines -- something like once a week for a month or X months -- wouldn't be too hard to achieve even for people who have no problem at all.

I don't necessarily think that this is about things being politicized, but it's a reaction and an attempt to actually be able to make clinical diagnoses by simply listing off the factors and trying to remove the subjectivity. In another lecture -- TVO ran a series of these for Mental Health Month, that you can almost certainly find somewhere at http://ww3.tvo.org/ -- they commented that one of the problems in the past was that a person could go to 5 different psychologists/psychaitrists and get 5 different diagnoses. This didn't make the field look all that great, so they're trying to standardize it ... and, it seems, are standardizing it too much.

Now, when I took intro psych a while back, one of the additional criteria for all of these things was "To the extent that it interferes with the person's life negatively", or something like that, and also that it wasn't considered a problem if it matched cultural expectations. I think for most college students, it wouldn't be a problem and would be culturally expected to have some binge drinking, but that if it went on too long and started having a negative effect -- such as generally missing or other important things because of either the aftereffects of binge drinking or because one wants to go drinking -- that would be a problem. So, I hope that this is indeed still part of the criteria.

But the DSMs are TRYING to cut nature at the joints. They just aren't succeeding, at least not yet.

Lee said...

Thank you, Prof. Blackford. I'll keep a sharp eye out for the discussion you mentioned.

David Duffy said...

It's worth looking at the actual proposal and the
rationale they give

The expectation is that the proportion of the population that meets the old DSM4 dependence and abuse categories will be roughly the same as meets the new. Furthermore, if you look at how the 11 criteria are worded, they don't come across as particularly expansive.

What it comes down to, as someone pointed out above, is that there is a continuum of behaviour, and the severe end looks like an illness to me. I don't think the Frankfurt willing addict is healthy, just because he is happy with his situation.

Verbose Stoic said...

David Duffy,

I think a lot of the complaint, at least from what I heard in the talk I referenced, is more that it only takes 2 of these, and some of these are pretty easy to get. College students will build their tolerance, for example, but that's not really a problem, but add in anything else and it suddenly is. If you needed 5 out of them, say, then it wouldn't be as much of an issue.

Dr X said...

The DSM diagnoses are functionally less the product of political influence than they are the product of economic influences.

In the US, diagnosis does not constitute legal grounds for commitment. Because of deinstitutionalization, tight state budgets, and tightfighted health insurers, the mental health and pharmaceutical industries are effectively turning mental disorders into economic constructs intended to broaden and solidify the grounds for reimbursement based upon American reimburser guidelines. It's all about making money within the context of the American system of health care coverage.

The DSM should be renamed the Diagnostic and American Reimbursement Manual.

And I say this as an American practitioner who relies on the DSM-IV-TR for payment from insurers. I know of no practitioners using it in practice for any other purpose.

Shatterface said...

The degree to which mental illness is 'real' (for want of another word) or socially constructed is an interesting one.

I'm bipolar II co-morbid with Asperger's.

The bipolar part is debilitating when I'm in a depressed cycle, but as I'm bipolar II rather than bipolar I, I get hypomanic rather than manic and present well within what I'd consider 'normal' parameters: over confident and over-enthusiastic, perhaps, but impatient and irritable. Not 'mental' as such, and not what I'd describe as 'disabled' by a long shot.

I take medication to stabalise my moods. I accept it is an illness, I think of it as an alien imposition on my real personality, and If there was a magic pill which would take away the condition I'd take it.

On the other hand, I'm rather low on the Asperger's spectrum, and as a comic collector and a Doctor Who fan pass for neurotypical within my social circle. Its part of me, I don't have a problem with it, and it wasn't even a problem at work until quite recently when my employer became obsessed with KMI targets and micromanagement.

What this has done is define a 'normative' behaviour I don't, and can't, conform to - and suddenly my idiocyncrasies became - in my empolyer's eyes - a 'health issue'.

Hence counceling sessions, ATOS referals for 'reasonable adjustments', endless sessions with the work psychologist, etc. for a condition I regard as 'normal' for me, and which I was actually happy with.

So I've got a 'real' mental illness, which is occasionally debilitating, and a condition which is mild and something I accept, but which has become something my employer has made into a disability by redefining my work conditions.

Shatterface said...

Just to reitterate - I'm low on the Aspergers spectrum. For many people it is genuinely debilitating. For me, outside work, it isn't.