Defining ‘Normal’ Behavior: The New DSM and the Old Manuals of Sin

Today’s NYTimes front page features an article on the new Diagnostic and Statistical Manual of Mental Disorders (DSM V), due out in 2013. The DSM is the psychiatric field’s encyclopedia of mental disorders which allows practitioners to determine who is mentally “normal” and who is not.

This is no small deal:

“Anything you put in that book, any little change you make, has huge implications not only for psychiatry but for pharmaceutical marketing, research, for the legal system, for who’s considered to be normal or not, for who’s considered disabled,” said Dr. Michael First, a professor of psychiatry at Columbia University who edited the fourth edition of the manual but is not involved in the fifth. “And it has huge implications for stigma,” Dr. First continued, “because the more disorders you put in, the more people get labels, and the higher the risk that some get inappropriate treatment.”

One concern is that the revisions for the new DSM have “been the subject of intense lobbying by advocacy groups.” Considering the fact that many of the new diagnoses will also come with prescription drug remedies, many worry that the pharmaceutical industry is playing a big role in expanding the diagnostic criteria in order to increase profits from psychiatric drugs. Many of the comments on the NYTimes page note that it seems the new DSM is a matter of politics rather than medicine, or another move by “big pharma” making money by drugging people.

From the EverydayThomist perspective, the problem with the new DSM is that it assumes too much normativity in human behavior. Human behavior is not only incredibly complex, it also varies a lot from person to person. Some children are born with more of a natural tendency toward moderation in food and drink; others are prone to excess. Some children are very shy; others are prone to excessive anger and aggression. Human beings are too diverse to be able to neatly label as “ordered” or “disordered” to the extent that the new DSM attempts to do.

It reminds me of the manuals of moral theology, especially those written at the end of the 19th and beginning of the 20th century which strived to precisely label and categorize every possible sin. This is, however, impossible, as Josef Pieper notes in his most excellent book The Four Cardinal Virtues:

How are we to react to a proposition such as this one, found in one of the most popular handbooks of moral theology: “To look at the private parts of animals out of curiosity, but without voluptuousness . . . is a venial sin”? Not to mention other distortions, it seems that here the limit beyond which casuistry becomes meaningless has been considerably exceeded. Propositions so constructed seem entirely to miss the true purpose and scope of casuistry, which is to provide a tentative approach and an auxiliary means for the practice of discernment. Is it not to be feared that a discernment schooled by such methods will be misguided toward an unrealistic rigidity and a prematurely fixed judgment, instead of toward a sober evaluation of the realities of life; and that this in turn may lead to a total incomprehension of the reality of man as a being who responds to the richly orchestrated world with every power of his soul, and thus reaches his choice?

The pre-conciliar moral manuals were striving toward certainty in their evaluation of human behavior, in much the same way that DSM V seems to be doing. Whereas the moral manuals wanted to define precisely in every possible case what could be considered “sin,” the DSM uses the more contemporary scientifically minded language of “pathology” and “disorder,” but the intent is the same–the desire for rigid and precise criteria to judge human behavior.

A virtue ethics perspective rejects the need for such certainty, recognizing that two people may do the same things, and yet act (in light of circumstances and intentions) in very different ways. As Josef Pieper writes,

It is temperantia, the virtue that realizes the inner order of man in himself, which St. Thomas has in mind when–in contrast to justice, in whose province that which is ‘properly and in itself right’ can and must be determined–speaking of ‘the other moral virtues which refer to the passions and in which right or wrong cannot be determined in the same fashion, because men vary in their attitudes toward the passions,’ he says, ‘therefore it is necessary that what is right and reasonable in the passions should be determined with reference to ourselves, who are moved by the passions.’ But especially in the province of temeprantia ‘we ourselves’ have the choice of innumerable possibilities: for example, to desire halfheartedly or wholeheartedly, to tolerate, to let things take their course, to give in to pressure or to be carried away. ‘Who could determine,’ writes the perceptive Thomist H.D. Noble, ‘who could determine when lack of control ends and where temperance begins?’ St. Thomas says that the realization of temperantia varies too much according to individuals and periods to allow the establishment of hard and fast, universally valid commandments.

Aquinas recognized in the 13th century that there was no such thing as “normal” human behavior. Which is why he referred to the virtues as powers within a person to help her realize for herself within a specific community with specific practices which behaviors would be conducive to happiness. But the problem for a lot of people with virtue ethics is that it leaves too much room for ambiguity, too much room for diversity in behavior which makes human beings, even the most open-minded contemporary human beings, very uncomfortable. So we’ve done away with sin manuals, but have we simply replaced them with an ever-expanding encyclopedia of mental disorders?

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4 comments so far

  1. Rita on

    I would actually argue the exact opposite point about the purpose of the DSM. The majority of the disorders in the DSM include a requirement that the symptoms must cause distress to the patient. This can be emotional, social, familial, physical, etc.

    Let’s take the example of sex addiction. This is not in the DSM IV, but will be in the new one. In the DSM V, none of the suggested criteria for sex addiction give a requirement on the amount, type, frequency, whatever of sexual activity that a patient must engage in before they can be given that diagnosis. However, it does include a clause that the sexual behavior of the patient causes distress to that patient. That means that if you have 2 people with the exact same sexual behaviors and exact same consequences of said behaviors, but patient A is OK with it and patient B is distraught, then only patient B gets that diagnosis. Patient A is psychiatrically A-OK. If this really was an attempt at creating a “rigid and precise criteria to judge human behavior,” then the behavior would define the diagnosis, not the degree of psychological distress. Sin, however, is still sin regardless of whether or not it upsets me.

    Another example – depression. It’s not simply the depressive symptoms that indicate the diagnosis, but the “significant distress or impairment” caused by the symptoms.

    When you say “a virtue ethics perspective rejects the need for such certainty, recognizing that two people may do the same things, and yet act (in light of circumstances and intentions) in very different ways,” I think that is a pretty accurate way of describing exactly what the DSM does. They don’t judge behaviors or actions alone, but look at them in terms of what it means to the individual. This can be both a blessing and a curse. In my example of sex addiction, both patients should probably be treated. Then again, in my depression example, you then spare non-distressed but symptomatic person the stigma of a compulsory label. It all makes psychiatric disorders pretty tricky to diagnose and treat.

    • everydaythomist on

      Rita,
      You make some excellent points. I should also mention that I am in favor of revising the DSM and I am not one of these people who think that psychiatric illnesses are just an illusion. However, I would say that distress is often something that can be controlled, and is frequently incited by societal pressure and normative judgments. Take homosexuality which was in the DSM III. When homosexuality was less socially-accepted than it is now, I am sure it caused quite a bit of distress among homosexuals, who probably felt that they could not function normally in society because of their sexual attraction to those of the same gender. Yet, when a homosexual person was part of an accepting, non-judgmental community, homosexuality was probably less of a handicap, even when the DSM categorized it as a mental illness.

      A child who might be prone to outbursts of anger and violence may experience a lot of distress if they are part of a community which does not tolerate, or worse, punishes such outbursts improperly. Rather than giving this child a diagnosis of temper dysregulation and medicating the perceived “disorder,” I suspect much of the distress caused to the child could be alleviated by a more welcoming, more patient community.

      I think the DSM is best used as a tool to “provide a tentative approach and an auxiliary means for the practice of discerning” what is a true disorder and what is simply the result of negative habituation, as Josef Pieper says the moral “sin” manuals and casuistic case books were meant to be. The problem is, the more specifically you try to define which behaviors are normal and which are disordered, whether referring to sin or psychiatric illnesses, the less room there is for prudential judgment.

      • everydaythomist on

        This article from the NYTimes further illuminates the complexity of defining mental illness, specifically referring to the decision to omit Asperger’s syndrome from the DSM V as well as widen the diagnostic criteria for autism. It also supports Rita’s point that the new DSM is less rigid, rather than more so:

        Moreover, large epidemiological studies have demonstrated that mild symptoms of autism are common in the general population. In particular, scientists have found that family members of a child with autism often exhibit isolated autistic traits. With autism, as with many medical diagnoses — like hypertension and obesity — the boundary lines are drawn as much by culture as by nature. Dividing up the workings of the mind is not as neat and orderly as categorizing species.

        The proposed new diagnostic criteria, by describing severity and functioning along a single continuum, would also capture the often unpredictable changes among children with autism. When Isabel was 3, she had all the symptoms of autistic disorder, but if she walked into a doctor’s office today as a new patient — a chatty, quirky high school senior — she would more likely be given a diagnosis of Asperger’s disorder. Narrow diagnostic categories do not help us understand the way a person will develop over time.

  2. Tablet Keyboard on

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