Happiness: in the Mind of the Beholder

The Positive Psychology movement, spearheaded by Martin Seligman, is attempting to figure out what makes people happy. We have idiosyncratic conceptions of what constitutes happiness. Indeed, happy has many synonyms: content, lucky, fortunate, delighted, glad... To be a happy human may entail many different states. Maslow’s hierarchy of needs provides a starting point. It seems reasonable to suggest that people need to have food, water, shelter, and security before they can start to assess whether or not they are happy. But beyond this foundation, what really matters? Is it your outlook on life? Your income? Relationships with friends and family? Happiness is multi-faceted and is certainly a gradable emotion.

Firstly, what exactly separates joy-junkies from melancholy-mopers? An article by Lyubomirsky and Boehm (2009) gives some pointers: 

Happy people:	Unhappy people:
·       evaluate experiences positively both at the time and afterwards ·       savour life experiences and consider how much better off they are in the present	·       see events more negatively at the time and afterwards ·       ruminate on negative experiences and consider how much better off they were in the past
When they don’t get into the university they applied for:
Happy people:	Unhappy people:
·       changed their opinions by favouring the institutions that did accept them and disfavouring the ones that rejected them	·       did the opposite by retaining their preferences for the institutions that rejected them and disfavouring their accepted one
In an experiment, participants solved anagrams in the presence of a confederate who either performed more quickly or more slowly than them. When the confederate performed more quickly:
Happy people:	Unhappy people:
·       didn’t change their perceptions of their own skills and abilities	·       demoted their own skills and abilities

Both of these groups of people tend to have the same experiences, but the most significant difference between them is the way they perceive the world and the strategies they use for processing life events. 

In day-to-day life, most people have a baseline happiness level. Positive events provide a boost to happiness, and negative ones cause it to drop, but sooner or later it returns to its original level. This is known as Hedonic Treadmill Theory. In other words, people become adapted or habituated to their new circumstances, although negative circumstances pack more of a punch (known as a negativity bias). Studies comparing the happiness of lottery winners with merely hopeful gamblers found no significant differences, providing support for the short-lived effects of (positive) life events on happiness.

Unfortunately Hedonic Treadmill Theory is rather deterministic and therefore rather a hindrance when considering happiness interventions. What’s the point in trying to improve your happiness when it’ll only snap back into place like a laggy band?

Lyubomirsky and Boehm (2009) discuss a Sustainable Happiness Model to explain what affects how jubilant we are. According to the authors, happiness is dependent on three things:

• (1) Your set point. Some people are ‘chronically happy’ (sounds more like an ailment) while others are pessimistic and dour on a daily basis. This set point, or baseline, is genetically determined. Twin studies have illustrated that happiness is heritable, since identical twins are much more likely than fraternal twins to have similar levels of happiness. Fifty percent of variance in level of happiness is down to our genes.

• (2) Your life circumstances. Your income, education, gender, age, ethnicity, health, personal experiences, account for 10% of your happiness.

• (3) Intentional Activity. The remaining 40%, therefore, constitutes what actions you decide to take in your daily existence. This includes acts of kindness towards others and expressing gratitude.

 

Newman and Larsen 2012 are critical of the idea that 40% of our happiness is within our hands (as am I). In relation to (1), they point out that heritability rates estimate the proportion of individual differences among a group of people that can be attributed to their genes. Accordingly, they cannot be applied to any one individual. Not everyone’s capacity to control their happiness is 50% determined by their genes.

Lyubomirsky and Boehm have been either sneaky or lazy by assuming that the leftover 40% must be entirely, uniquely volitional actions. So two fifths of your happiness is determined by intentional actions just... because... they need something to account for the leftover 40%? That doesn’t seem very scientific. As Newman and Larsen note, the list of states and events that fill this 40% is potentially limitless. And what of destructive and pervasive life events beyond our control such as unplanned pregnancies, evictions, bankruptcy... You can’t control whether or not these happen and how they will affect you.

We’ve learnt that negative affect has a more significant impact on happiness, so perhaps we should try to remove or prevent this, rather than bolstering positive affect. The problem here is that a lot of negative affect is caused by events that are out of our control, so there is little we can do about them. 

Lyubomirsky is well-known within the branch of positive psychology and has published books and articles based on the 50-10-40 proportion combination above. Her efforts are noble, but the results are misguided and overgeneralised. 

Psychology has demonstrated that people like to be happy and in control – the public is eager to latch on to any old book or article about how to improve (and by definition control) your happiness, made all the more appealing by the words ‘science’, ‘research’ and ‘proven’ which, this case, appear to be misnomers.

My first experience with Autism

Autism is no longer a blip on the radar of public consciousness, thanks in part to television programmes like Louis Theroux's Extreme Love (BBC 2012) and to some extent commentary on television characters like Sarah Lund in The Killing. Unfortunately there is still a long way to go before Autism Spectrum Conditions (ASC) are recognised, accepted, and understood by laymen and clinicians alike. As the saying goes, "Once you've met someone with Autism... you've met someone with Autism." And that's just it - although individuals on the Autism Spectrum share impairments in social interaction, communication, and restricted behaviours, they all fit somewhere along a spectrum.

Last night I began volunteering at Daisy Chain, a charity offering support and respite for families affected by autism, as well as youth groups and a plethora of activities for children and young people diagnosed with an ASC. The session I attended was the Youth Group, and I'd say that the average was around 15. I think the teenagers at this group are classed as having 'High Functioning' Autism - one of the other volunteers invited me to sit down and chat with them, "they're very bright y'know." And so they were.

It really wasn't what I was expecting. The conversations being had were lucid, witty, interesting, and entertaining. Their recall for facts was very impressive, one of them reciting the latin name for a particular breed of alpaca and another sharing his extensive knowledge of Lord of the Rings. In one way, I failed to see how some of them had achieved any kind of diagnosis whatsoever; I'm not sure I would have recognised some of them as having Autism were it not for the fact that they were attending the session.

An impairment in social interaction is one facet of ASCs. The rules of conversation are difficult at best. Knowing when to speak, how to respond, who to look at, how to express disinterestedness without offence... I did notice, at times, a flagrant disregard for these rules when we were sitting in a big group, such as shouting across the table and carrying on the conversation despite the interlocutor turning away. At one point, while talking to someone about driving lessons, a girl to my left started telling me that I was annoying, but she didn't say it just once... rather she repeated 'you're annoying' throughout the best part of my conversational turn.

One boy, quieter than the others, seemed desperate to join in the conversation, but didn't know how to relate to the topic. Instead, he interjected the odd off-topic phrase ("Pie!" seemed to be a favourite) hoping it would catch someone's attention. On one occasion he began speaking, but was overtaken by another and immediately stopping himself, he looked down despondently muttering something.

To some extent this behaviour doesn't seem so aberrant; they're teenagers playing with boundaries, forming identities, making friends.

Now, here is the point I really wanted to make in this post. On my way home from the Daisy Chain centre I was waiting at the bus stop alone. Suddenly, three youths appeared out of nowhere and came into the bus shelter. I knew something was wrong when they sat RIGHT next to me. This kind of experience has conditioned a fight/flight response in me so I was on guard. The ringleader proceeded to talk to me despite seeing that I had earphones in and was looking in the opposite direction. In a stupid voice, he said hello and asked me where I was going and if I wanted to buy his "very genuine" pair of headphones. My approach was for minimal interaction, so I said what I had to and resumed looking away. However, he continued to talk to me and even asked if he was getting on my nerves, which he knew he was. I'd class this as an impairment in social interaction, wouldn't you? Although I doubt he was diagnosed with an ASC.

Tomas Szasz is famous for his anti-psychiatry approach, claiming that society labels people as 'mentally ill' or as having a 'condition' because they are different (AKA 'medicalising normality'). What was so different between the chavs and the people at Daisy Chain? The teenagers in the youth group were far nicer people, intelligent, interesting, funny, and yet it is they who have a 'condition'. Is anti-social behaviour not classed as a condition?

I'd like to talk to someone who can tell me why High Functioning Autism needs a diagnosis, and what is to be gained from this official clinical recognition. Of course I only saw these guys for 2 hours. Something leads me to think that every day is not the same...

Consistent Exerise and Cognition

A recent study investigated the effects of regular exercise on cognitive function. In an experimental condition, students took part in a regular exercise program for four weeks before completing cognitive and affective tests.

The researchers found that indeed, a mere 30 minutes of physical exercise once a day for the period preceding the tests was enough to produce measurable benefits to both cognition and perceived levels of anxiety. For this to work, though, exercise needs to be regular; exercising only on the day of the test did not produce the same benefits. The key is regularity rather than intensity.

When I started swimming (semi-)regularly last year I was better able to recall new French vocabulary I was learning at the time. The study assessed novel object recognition memory (NOR). This involved showing participants a set of objects before the 4-week block and afterwards. Those who completed the physical exercise showed improved performance in recognising which objects they had seen 4 weeks earlier.

Other studies have provided evidence of positive benefits to attention, decision-making, and mental health. The question is whether exercise benefits other kinds of memory. Object recognition can be applied to words. Written words are objects with a particular shape and character, so it stands to reason that improved object recognition would translate to written word recognition. 

My question is whether exercise can help us process and store words on a deeper level to the extent that we are able to actively recall them without the prompt of a visual object.

The Problem with Psychiatry

I came across a very erudite article by Ronald W. Pies, MD (Psychiatric Times Vol 29, No.3 March 1, 2012). In it, he explores the foundations of public dissent at the current state of psychiatry practice in America. I wanted to share his reasoning:

 

I think the first point is the epicentre of the problem, which is carried off in shockwaves through the media. At the heart of this issue is classification and diagnosis, enter the DSM. Dr. Pies proposes some radical changes to DSM-5, the latest edition due to be published next year.


Click here to read the article (you may need to register [it's free]).

Chomsky's view on language - broken down

So while rummaging around in my room, I found some dusty old notes from L359 Phonological Development, a 3rd year module of my Bachelors. I used a dictaphone that year, so my notes are really top notch. I found something about Nativism and Chomsky's argument broken down into nicely digestable chunks. I've colour-coded this version for extra clarity.

“It seems plain that language acquisition is based on the child’s discovery of what from a formal point of view is a deep and abstract theory – a generative grammar of his language – many of the concepts and principles which are only remotely related to experience by long and intricate chains of unconscious quasi-inferential steps. A consideration of the character of the grammar that is acquired, the degenerate quality and narrowly limited extent of the available data, the striking uniformity of the resulting grammars, and their independence of intelligence, motivation, and emotional state, over wide ranges of variation, leave little hope that much of the structure of the language can be learned by an organism initially uninformed as to its general character.”

Chomsky, N. (1965). Aspects of the Theory of Syntax. Cambridge: MIT Press.

• the character of the grammar that is acquired: the astounding complexity of language
• the degenerate quality and narrowly limited extent of the available data: speech input from adults consists of interruptions, mistakes, false-starts, and so on; the fact that infants only hear a finite number of utterances during development, yet are later able to produce an infinite amount of utterances
• the striking uniformity of the resulting grammars: the idea that all English speakers will agree when a sentence is ‘correct’ or not (although people do disagree on subtle grammaticality-judgement tasks)
• and their independence of intelligence, motivation, and emotional state, over wide ranges of variation: language must be considered a disparate faculty since it bears no relation to intelligence, motivation, etc.
  
• uninformed as to its general character: Chomsky argues that considering the four points above, it is very unlikely that humans could master such a complex system in such adverse circumstances without being ‘predisposed’ to learning it from birth. In other words, infants must be prepared in advance to learn language and have access to some kind of innate structure or representational system.

 
Chomsky's theory is formidable and necessarily posits a Universal Grammar - the claim that Czech, Japanese, Hebrew, Swahili, Hindi, English, Swedish, Portuguese, and all other languages share a common underlying structure. There's a good deal of evidence for this.
However, Emergentism, the arch nemesis of Nativism, claims on the other hand that in fact we are not born being predisposed to linguistic structure but that instead we possess extremely powerful learning mechanisms. Improving technology and investigative techniques have allowed researchers to explore this idea more thoroughly, and I intend to cover it at a later date. It's really a very interesting topic because it incorporates attentional as well as cognitive processes.

ADHD (Attention-Deficit Hyperactivity Disorder)

ADHD: Please Pay Attention

(skip to the end for a bitesize summary)

‘ADHD is a condition that affects an individual’s ability to control attention and behaviour in an optimal and adaptive manner. It can cause individuals to become overactive and impulsive. The condition is frequently associated with educational underachievement, antisocial behaviour, and poor psychosocial adjustment.’ (Snowling and Hulme 2010). 

Attention-Deficit Hyperactivity Disorder is a story told in two parts: Hyperactivity/impulsivity (HI) and Inattention (IA). Individuals can be diagnosed with the predominantly HI or IA variety, but most are diagnosed with the combined type, hence AD+HD. More about the symptoms: NHS: symptoms of ADHD

ADHD is a hot topic. There are disagreements as to whether it is under- or over-diagnosed, and some even doubt its existence. Prevalence is in the range of 3-5% of UK school children and is more common in boys. Adults are also affected as the condition doesn’t diminish with age. 

Depending on your stance, it's caused either by: a deficit in executive functioning in the brain (control of inhibition and voluntary action thanks to dopamine and norepinephrine); an inability to defer gratification (called delay aversion), genes, or parenting styles.

Symptoms and diagnosis

• To be diagnosed with ADHD, both symptoms of inattention and hyperactivity must be present in at least two different settings, e.g. at home and at school, for at least 6 months.
• Clinicians are not required to observe children; rather, they rely on third-party accounts from teachers and parents, which surely plays a role in its misdiagnosis.

Adapted from Frederickson, N., Cline, T. (2009). Special Educational Needs, Inclusion and Diversity. London: OUP.

Overdiagnosis

A lot of research has assessed commonly held beliefs that ADHD is under- or over-diagnosed. The latest^[1] asked German psychiatrists to examine sample cases and give recommendations of diagnoses and treatment. Strikingly, the researchers found that gender played a role in likelihood of receiving a diagnosis of ADHD, with boys being more regularly misdiagnosed than girls because they fit the ‘prototypical criteria’ for the condition. These findings are pretty damning, although they are hardly comprehensive.  

Other research suggests that in fact global overdiagnosis is a myth. Sciutto and Eisenberg (2007)^[2] found no justification for the claim that ADHD is overdiagnosed, pointing instead to public perceptions of the disorder.

Dr. Daniel Conner^[3] offers some explanations of overdiagnosis:

·          Comorbidity (concomitant but unrelated conditions): as many as 75% of children diagnosed with ADHD also meet diagnostic criteria for other conditions like oppositional defiance disorder, depression, anxiety, and learning disorders. The trick is to tease out a set of symptoms specific to ADHD.

·          Inaccuracy: many clinicians are purported to use general rules of thumb and heuristics (trial-and-error methods) rather than relying on consistent diagnostic criteria. It seems that they rely on prototypical symptoms and characteristics, hence why boys are more likely to be diagnosed. 

·          Cognitive bias: this is an idea from social psychology whereby an individual actively seeks evidence that confirms his or her own theories and reasoning, “I’ve seen lots of kids with this condition, and you’re a lot like them, so you must also have it.”

·          Sex: as the German research shows, practitioners rely on prototypical criteria, which do not include girls. Girls are under-represented in this condition as they tend to display lower levels of disruptive behaviours, but are more likely to show inattention and social impairment.

In one study, children with late birthdays (making them younger than other classmates) were more likely to be diagnosed since their younger patterns of behaviour are misinterpreted. “We need to allow children to mature at different times and rates without pathologising these patterns”, says David Traxson^[4]. He claims that DSM-5 will only exacerbate this problem.

Overmedication

Dr. Conner explains that before 1970 diagnosis of the condition was ~1%. Throughout the following decades the US government’s response to ADHD provided impetus for pharmaceuticals to begin feverish testing. In 2007, diagnosis rates were nearly 8%, but only 4.3% of these cases were prescribed medication. ADHD does not necessarily require medication, as there are plenty of other therapies available. Over-prescription is found in some regions, but it is certainly not a global problem. 

Does the rise from ~1% to 8% indicate overdiagnosis? Definitions of the disorder have changed since it was first described in 1902, with more focus being given to inattention by the 1980s. Broadening of the criteria necessarily includes more children in its scope, but does not represent overdiagnosis.

Recent findings^[5] from Canada do indicate overdiagnosis and overmedication, suggesting that ADHD medications may be prescribed to deal with related conditions like oppositional defiance disorder (ODD) and conduct disorder. After all, criteria for these conditions are very similar.

Could there be a problem with the boundaries between these different disorders? If the same drugs work for ADHD, ODD, and conduct disorders, it is not possible that they are addressing the same problem, a common deficit running through each of them? It seems natural that kids with ODD who are argumentative, prone to tantrums, and are often angry and resentful would also be inattentive and hyperactive.

The legitimacy of ADHD as a disorder

So what’s the problem? Describing and explaining this disorder seems like pulling a square through a circular hole or struggling interminably to make a line of best fit. There are problems with its legitimacy in both public and scientific spheres, but I won’t go as far as Thomas Szasz in denying its existence, or indeed all other mental health disorders for that matter.

Social Construct Theory

A Social Constructionist explanation of mental illnesses or disorders is that they are not valid medical diagnoses, but rather excuses we have constructed in order to deal with socially unacceptable behaviour. Firstly, there are no robust neural correlates of ADHD. Secondly, comorbidity is extremely high (75%) which means that it can’t be considered a distinct disorder in its own right; it’s the leftovers of another disorder. And thirdly, ADHD is frequently associated with underachievement and poor psychosocial adjustment: The symptoms derive from these facts – how else would you expect poorly adjusted, low-IQ children to behave?

Our society has degraded to a point at which we can’t hold responsibility for this disgusting behaviour. There has been a ‘breakdown in the moral authority of adults’. The doctrine of ‘mother blame’ says that we use ADHD as a way of placing ultimate responsibility with the child’s primary attachment figure and their deficient child-rearing. Schools and teachers have lost grip and are not able to control children’s behaviour: a diagnosis of ADHD is a convenient way to relieve the burden on the classroom and the teacher. The pharmaceutical industry resides in shady corners, furtively offering Ritalin and Adderall to parents and clinicians seeking a quick fix.

In my opinion, what Social Construct Theory does is explain the views of the general public about the status of ADHD. What it doesn’t do is explain the disorder itself.

A Distinct Disorder

In fact, there are neural correlates of ADHD. It isn’t correct to emphasise dysfunction in any one region; the pattern is spread out, yet still distinctive^[6]. Studies have consistently found patterns of frontal hypoactivity prefrontal cortices where executive function arises. There is strong evidence for the role of genes in development of ADHD. Research has also looked at endophenotypes – ways to inherit a tendency to develop ADHD which would be triggered by environmental or social factors. And actually, severe hyperactivity is a strong predictor of later psychosocial maladjustment rather than ADHD being the effect of it.

Dr. Connor puts it best:

“Doubt and confusion as to where this disorder fits into the general spectrum of illness further feeds the general perception that ADHD is a socially constructed disorder rather than a valid neurobiological disorder. This increases the public’s concern that ADHD is overdiagnosed and stimulants are overprescribed."

It appears that misdiagnosis is merely one part of the puzzle.

FAQ

Attention-Deficit Hyperactivity Disorder is a slippery fish. To say that it (supposedly) affects so many people, it is poorly understood, and this is not helped by the general public’s acerbic criticism.

• Is ADHD overdiagnosed? In some places, yes.

• Why? It often occurs with other disorders that share symptoms, clinicians don’t tend to stick to strict rules, and they rely on prototypical criteria (like being male)

• Is it overmedicated? Research suggests not, but ADHD medications may be used for related disorders, distorting the picture.

• Some say that it isn’t a real disorder – explain. It’s seen as an excuse for slipping societal moral standards and bad parenting, which the pharmaceutical industry is cashing in on.

• But some say it is a real disorder – explain. Neurological studies have found distinctive patterns of brain function in people with the disorder, genes play a strong role, drugs have a significant effect in treating it, and it can predict later psychosocial maladjustment.

DSM: The Bible of Mental Illness

The Beleaguered DSM: a love story with consistency and classification
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been hailed as the ‘mental health bible’ for psychiatrists and other clinicians. It is used to diagnose mental health disorders such as depression, anxiety, ADHD, schizophrenia, bipolar disorder, autism, among many lesser-known maladies of the mind. The DSM is updated periodically, inevitably along with an increase in the number of diagnosable disorders (see table). It has been dogged by criticism since its conception but has also served as a reflection of changing times; in 1980 DSM-III listed homosexuality as a mental disorder.

Good Intentions
Although collated and published by the American Psychological Association, the DSM is also used, or at least referred to, in the UK. Conceptually, it is wonderful; an all-encompassing one-stop-shop for clinicians to consistently diagnose mental health disorders...right? As Michael Conner ^[1] puts it, ‘the mere fact that any diagnostic system is reliable does not mean the process is valid, useful and not harmful.’ One particular sample of mental health patients found that diagnoses of schizophrenia ranged from 163 to 19 cases, depending on the interpretation of the diagnostic criteria used.

Conner sees mental health diagnostic processes as no less sophisticated than those used to diagnose headaches or inner ear problems. He distances subjective psychological problems from hard-nosed, matter-of-fact medical diagnoses of, say, cancer, wherein objective variations in biochemistry become arbiters of diagnosis instead. The premise is that subjective diagnosis, by definition, cannot be scientific and as a result the concept of consistency in psychiatry is flawed.

	Publication Date	Major diagnostic categories	Possible Diagnoses
DSM-I	1952	3	106
DSM-II	1968	11	185
DSM-III	1980	15	265
DSM-III-R	1987	15	297
DSM-IV	1994	17	365
DSM-IV-TR	2000	17	365
DSM-5	2013	?	?

Adapted from The Development of the DSM

One need only look at the table above to recognise that they didn’t get it right first time. In fact, the biggest increase of possible diagnoses was between DSM-I and II. Post-WWII America was discovering its sensitive side by spending more time on the psychiatrist's couch. I think there is no doubt that history and culture played a part in fleshing out the DSM - what were doctors supposed to do with all those shellshock sufferers?

An Example
Before we move on, it may be useful to look at an example of how the DSM defines disorders. I have chosen diagnostic criteria for a Major Depressive Episode (depression). You needn’t read it all, but it’s just to give an idea of the layout and kind of information provided:

Diagnostic criteria for Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either: (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).  (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)  (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.   (4) Insomnia or Hypersomnia nearly every day  (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)  (6) fatigue or loss of energy nearly every day  (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)  (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)  (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide  ....

Taken from DSM-IV.

The Latest Addition to the Family
According to an FAQ on the specially set-up DSM-5 website ^[2], new technologies (primarily fMRI) and intensive research mean that the Bible must be updated. Surely no one would argue with this; it would be preposterous to ignore the tasty fruits of contemporary research. However, some have highlighted links between DSM-contributors and the pharmaceutical industry ^[3],[4] . Is the number of diagnoses being tampered with in order to deepen pockets? More possible disorders equates to a wider range of drugs to treat them, right? I am sceptical of this claim – they are clinicians after all, and wouldn't you be worried if they didn't have any links to the industry that bases its products on their research?

Further enquiry reveals that DSM-5 (which is getting rid of Roman numerals to be down with the kids), has been in pre-planning talks since the beginning of the 21^st century. Even previous revisions were taken into deep consideration, being published 7 and 6 years respectively after their progenitors (I refer to DSM-III, DSM-III-R, etc). According to the website, “work groups (made up of global experts in various areas of diagnosis) have looked at what elements of the current edition (DSM-IV) are working well, what elements do not meet the needs of clinicians and how best to correct those concerns.” So at least they're trying.

Some recent recommended amendments include the collapsing of Autism, Asperger’s, Pervasive Developmental Disorder, and Childhood Disintegrative Disorder into one ‘overarching category of ASD [Autism Spectrum Disorder]^[5], as well as the reduction of personality types to six, including: antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal. “In the past, we viewed personality disorders as binary”, says Dr. Andrew Skodol^[6]. “You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.” The Personality Disorders Work Group advocates a more dimensional approach, as opposed to a categorical one: as Dr. Skodol says, this kind of thing simply isn’t black or white as patients may exhibit characteristics that straddle boundaries.

Medicalising Normality

Chair of the DSM-IV task force and staunch opponent of the latest edition, Dr. Allen Frances has voiced his concerns that DSM-5 will “medicalise normality”^[7]. He alludes to the over-diagnosis of ADHD (something I will blog about separately at a later date), ‘false epidemics’ of binge-eating and hypersexuality, and over-prescription of antipsychotic medication. In Psychology Today ^[8], he blames fads for apparent surges in overdiagnosis, but who is guilty of giving into the fad? Surely he must mean the psychiatrists themselves, since they are the ones who are doing the diagnosing. And is it never acceptable that certain conditions may be more prevalent today than previously?

Perhaps Frances' reaction is bitter and antagonistic since losing his former level of authority and control with the previous edition. Dyslexia was once scorned and laughed at as a pseudo-disorder. Today it is (pretty much) widely accepted by the psychological community of clinicians and researchers as a legitimate disorder, for which support is available. Dyscalculia, a congenital condition in which leaves the individual without a ‘basic feel for number’, is "rather where dyslexia was thirty years ago"^[9]. In other words, its existence is disputed, although it is listed in DSM-IV as 'mathematics disorder'.

A disorder is simply a label for a specific set of symptoms or characteristics. Unfortunately we’re all too aware of what can happen to labels, namely negative associations and inappropriate use. I have heard people complaining – yes, complaining – that the label ‘dyslexia’ used to be commonly known as ‘stupidity’. People bemoan the fact that they have one less way to offend others who would formally have been openly subject to another label: stupid. While we’re at it, dyslexia bears no correlation with intelligence.

My stance is that advances in diagnostic tools and research have allowed us to investigate the previously arcane and clandestine workings of the mind. A lot of time and resources have been poured into researching cognitive faculties of people who struggle with numeracy. The result has been the classification of a new disorder.

What is a disorder? It's a pattern (of behaviour) that is not considered part of normal development. In 1980 it was argued that homosexuality was indeed within normal development and variation, much to the chagrin of DSM-III authors. But here's the thing - homosexuality is not a disability. It doesn't represent a deficit in functioning or some kind of problem to be overcome. The point I'm trying to make is that a set of behaviours can and should be termed a 'disorder' if it negatively affects the individual's life.

So what's wrong with those 'false epidemics' of binge-eating and hypersexuality? Why is Frances so resistant? If we, as psychologists and fellow compassionate humans, can do anything to help these individuals, why would we deny them this?