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There has been a lot of media coverage of psychiatry lately. Friends and colleagues have handed me lots of articles in newspapers and magazines to read and blog about. It’s a bit overwhelming. One of the topics is the development of the new DSM V (Diagnostic and Statistical Manual) for psychiatry. The media coverage I have read is critical of the field for the apparent tendency to develop a diagnosis for every variation in human behavior that can be described. This is condemned as an effort to attribute various forms of misbehavior to “disorders” or “illnesses”. That Tiger Woods is in treatment for “sex addiction” for his multiple infidelities highlights the issue of sexual rule-breaking. When are serial affairs a symptom of a disorder? What is the role of choice and free will? How do we factor in morality?

You can read the proposed critieria for all the DSM diagnoses at the American Psychiatric Association website and you can also register and submit comments to the APA about the diagnoses. As you think about this, please consider the problem that Psychiatry is trying to tackle. We need some organized vocabulary about mental illness, emotional conditions and behavior problems in order to clearly communicate with each other, other medical specialties, our patients and the public. We also need this vocabulary to design research and test treatments. So, as messy as it is, it needs to be done. A cardiologist can diagnose heart failure by history and examination and confirm it by diagnostic tests, such as echocardiogram. A neurologist can diagnose a stroke by history and exam and confirm it by CT scan or MRI. A dermatologist can send a culture sample to the bacteriology lab to confirm a diagnosis of a fungal infection. As a psychiatrist, I do not have any diagnostic scans, cultures, blood tests etc to help me confirm a diagnosis of depression or schizophrenia. How murky it gets if the possible diagnosis is “sexual addiction”.

There is a new diagnosis proposed for the DSM V called “Hypersexual Disorder”. Even within the field of mental health specialists in the area of sexuality, there is much controversy about this diagnosis. No one wants to develop a diagnosis that inaccurately labels or stigmatizes people with normal behavior. But how do we characterize and “label” variations of behavior that nearly all of us would say are outside the normal range? How much viewing of pornography at work constitutes an abnormal preoccupation with sex? One hour daily? Six hours daily? Having lost three jobs over this and continuing to do it after landing the next job? Masturbating compulsively multiple times daily to the point of tissue damage and bleeding? The problem for the APA is how to define these difficult things in a useful way. I am glad I do not have that job.

And Tiger Woods? I don’t know the man so I have no comment on his diagnosis or lack thereof. I do know that historically men with money and power have had lots of access to sexual partners. This is not new. I also know that there is a high rate of infidelity in marriages. Also, not new. What I have to struggle with as a psychiatrist, is when the factor of a mental illness or disorder is also at play.
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I hesitate to wade into the media outcry over the American Psychiatric Association’s discussion about whether to create a new diagnostic category, Post-Traumatic Embitterment Disorder. Let me start by declaring myself a frugal diagnostician. I believe that we are better served with fewer diagnoses than more diagnoses. There are “lumpers” who tend to combine similar symptoms into broad categories and there are “splitters” who tend to define lots of multiple diagnoses and sub-types of diagnoses etc. I am a “lumper” for sure. It may stem from my role as a treating clinician and not a researcher. But I think even if I were a researcher I would be looking for the bigger picture and not reducing mental phenomena into smaller and smaller pieces. Let me also declare that I see mental disorders on a continuum of severity, with normal range responses anchoring down one end of the spectrum and unmistakably pathological responses anchoring down the other end. In the middle is the vast grey zone in which it is a judgment call to determine if something is normal or is a disorder. As with any judgment call, it depends a lot on who is making the call and the specific circumstances surrounding the call. It also depends on who is the recipient of the judgment call. Factors such as culture, age, gender, political beliefs, religion, occupation, socio-economic class, sexual orientation, marital status and physical appearance can influence the outcome. Interestingly, these factors are influential for both the patient and the doctor when it comes to making a diagnosis. The more alike the patient and the doctor are, the less likely it is for the doc to diagnose a mental disorder. The old joke that is not funny is that an alcoholic is someone who drinks more than the doctor. You can see why continuing research into psychiatric diagnoses is important to make them more precise and reproducible.

So what about this debate about Post-Traumatic Embitterment Disorder? Bitterness can be a natural reaction to difficult unfair painful life experiences. I think we all can agree on that. Is there a point where bitterness becomes a mental disorder? How painful and unfair do the experiences have to be for us to consider bitterness normal and not a symptom of a mental disorder? How do we assess the influence of unrealistic expectations in life in producing bitterness? Someone could be bitter because they are aging or because they have to pay taxes or because they hit every single red light on their way to work. This bitterness seems out of the normal range since realistic expectations of life include these events. In my mind, this does not prove that this is a mental disorder as much as it is the result of unreasonable thought patterns. You might say, aha, that proves it is a mental disorder.

This general debate has also raged about when shyness becomes Social Anxiety Disorder or who gets to define what exactly Hypoactive Sexual Desire Disorder is. For a viewpoint against calling bitterness a mental illness see this link. For one in favor, check out this link.

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