In which we continue our exploration of the definition of a mental disorder:
DSM-5 (page 20): “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning…The diagnosis of a mental disorder should have clinical utility. It should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients.”
I am beginning this blog post the same way that I began the last because the American Psychiatric Association standard definition of a mental disorder in the DSM-5 is the lens through which we consider, investigate, understand, and treat mental illnesses. Since these categories are intended to be fundamentally human, it is also one way we can understand ourselves.
It’s common for students upon getting their first copy of the DSM when studying Psychopathology in a master’s class to see themselves in all or most of the diagnoses. There’s a reason for this. If you don’t know people who are mentally ill to use as models for the various disorders and if you’ve led a relatively normal life away from mentally ill people, how else can you start to understand each mental disorder except to look inside yourself? And any diligent self-investigator with a will to discover and time to spend reflecting will find the sought-after symptoms lying dormant. “After all”, the thinking goes, “we’re all nuts. So, I must be, too.”
It’s true that, if you look for symptoms to make diagnoses, you can find them anywhere and everywhere. Just like in art, if you look at a painting long enough, you may find yourself seeing things that you have never seen before. These “discoveries” may be the product of an overactive imagination or may arise from the need to render meaning from things that are not easily understood. How else can you get an A in Psychopathology?
To illustrate, I present the mental disorder that everyone loves to see in the movies, the diagnosis that everyone understands instinctively, Antisocial Personality Disorder or Psychopathy. Who is not fascinated by Hannibal Lector? He’s the fun guy who not only kills, but does it brutally and with imagination. Charles Manson didn’t even commit a murder, but had a pack of followers who killed for him. And, heck, he’s even getting married after all these years in prison. Should someone who commits murder be considered mentally ill by definition, as the DSM would suggest? Should they be allowed to marry, perchance to reproduce? Or are they just criminals? Are they both mentally ill and criminal? Here’s the definition:
DSM-5 (page 659), “The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood.”
One may wonder whether anyone suffering from Psychopathy has ever been psychiatrically treated with success. Answer: no. The only treatment for Psychopathy that is accepted by professionals and the community alike is to lock the person up. And we have an entire industry dedicated to treating Antisocial Personality Disorder by putting those with the disorder on the inside of stout walls enclosed by razor wire. This would suggest that this is a social problem, not a mental one. It is included in the DSM because it meets the standard of emotional and behavioral dysregulation, not because there is a treatment for it and not because the symptoms are recognized in any other context outside the community in which it appears. That is what makes this a morality play, a moral lesson taken from our daily experience as we manage to live in increasingly large groups.
I recall reading a Superman comic as a child in which our hero treated his former enemy Bizarro, who was his super counterpart in an alternate Bizzaro universe. How did he do it? Superman simply exposed Bizarro to a mind healing device that was a light coming from a hairdryer-like machine directed at the top of Bizarro’s head. Not that a comic book could cure an Antisocial Personality in any realistic way because none exists.
Antisocial Personality Disorder is accepted as primarily a behavioral problem that, at its core, manifests as a lack of conscience. How do you teach conscience to someone who doesn’t have any? Anecdotal information tells us that most people, not all, develop conscience, even when they did not previously have much of one, by getting abused or taken advantage of by others on one occasion or repeatedly over time, causing them to realize what it is like when you find yourself being the victim rather than the victimizer. This is how jail therapy can be most helpful as Antisocials are forced to live in close proximity with others with the same diagnosis. In this situation, even top dog can fall to the bottom depending on age and circumstance, but they don’t always.
Take the case of Richard Speck, killer of nine student nurses in Chicago, who was placed permanently in solitary confinement and who was able to turn it into his version of a vacation home, complete with boyfriend, money, and drugs. He even started taking female hormones and grew breasts, but didn’t get the surgery. He had the resources to make a home video of his life in prison to show the world the kind of existence he created for himself. Unfortunately, that video is not currently available on YouTube, but this video about him is. https://www.youtube.com/watch?v=t0V8cqpyjk4&list=PL2C5E54081845D7F1&index=4
Outside the lack of compassion that characterizes Antisocials is the tendency by all of them to be aware, even hyperaware of where the lines are drawn in defining what is legal vs. illegal and violating other’s rights. The point is that you can rob a person or a bank, but if they don’t catch you with the money or with anything to tie you to the robbery, then you are just like everybody else, an average, know-nothing, boring person who can disappear into any crowd. Similarly, for a batterer, the perception is that you are only a batterer as long as you are battering; and, as soon as you stop that behavior, you can also disappear as long as you can convince an investigating officer your wife’s bruises were from a fall, only to reappear later on as the rule-breaker that distinguishes you and makes you interesting.
The DSM tells us and the Richard Speck video above would confirm that all these feelings of specialness and invulnerability are maintained and enhanced by drugs and alcohol. Otherwise, Antisocials are non-descript, even to themselves. But, down a pint or snort a line and the shy, withdrawn, retiring individual in front of you grows to immense size and stature, like Mighty Mouse.
I am reminded of the time when I was Director of a program to help women released from incarceration transition to community living. One afternoon, a woman came into my office to apply, however half-heartedly. “I bet you’ve never met anyone like me.” “Actually, I did meet someone like you this morning. In fact, she said exactly the same thing you just did.” I don’t expect originality from Psychopaths. The only thing I look for is how far they are prepared to go to distinguish themselves by breaking the rules. The rules are always there to be broken. It’s how far you think you need to go to set yourself apart from the rabble that is at issue.
I am also reminded of my older brother, who specialized in stepping into and out of the realm of accepted behavior as he violated others’ rights to suit his narcissistic needs. He also perceived himself as unique and believed himself to be a genius. As I mentioned in an earlier post, he would practice his chameleon-like personality changes and behavioral morphing on me, all the while telling me what an idiot I was. Now, many decades later, I have no problem confessing my stupidity, even with a doctorate because to me it is irrelevant. What is relevant is how and when a person is caught flaunting accepted social rules and the severity of the consequences they face. My brother was a truly brilliant chameleon. He always kept someone to prey upon, that is, until someone preyed upon him. He was shot to death three days after his 65th birthday. I had not been in contact with him at all for over 30 years and no regular contact for close to 50. Why? Because frankly, he and others like him are not all that interesting to me. I got my lessons early and moved on with the hope that I can help others avoid the same fate.