[vjulian]

What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm…by Americans. The DSM in many ways represents the worst of so-called social science.

[connicpu]

But conceptually in the DSM most disorders are defined by whether they cause hardship in the patient's life. Whether that means some disorders would not have to be considered disorders in an ideal society is irrelevant for this context, because people need help navigating the society we have.

[noosphr]

Remember that in the US slaves wanting freedom was a mental disorder that made it past peer review: https://en.wikipedia.org/wiki/Drapetomania

[dlivingston]

Reading your linked article, it's clear that this was viewed as absolute quackery even back then, and is about as conflict-of-interesty as you can get: commissioned by Louisiana at the height of the Civil War, and proposed by a doctor who served in the Confederate Army [1]. His suggested treatment for Drapetomania was "whipping the devil out of them".

[1]: https://en.wikipedia.org/wiki/Samuel_A._Cartwright

[noosphr]

This was proposed a decade before the war started and was reprinted widely in the Southern States. That the North found it ridiculous is a bit like saying that because the Chinese Academy of Sciences says there is no such thing as autism then it's obviously viewed as quackery in the West too.

[8bitchemistry]

Are you able to tell us a bit more about the Chinese Academy of Sciences saying there is no such thing as autism? I was curious but cannot find anything about this.

https://en.wikipedia.org/wiki/Autism_in_China

[esalman]

There's none lol. I may have participated in studies as a researcher partially funded by Chinese academy of sciences because we had Chinese collaboration, and some studies involved autism biomarker research.

[mothballed]

Slaves wanting freedom is a mental disorder if it is maladaptive, debilitating, and infeasible in their circumstance, no? Being crazy doesn't mean you're wrong, it could mean you are right in a world where you must be wrong to survive.

[lioeters]

“It is no measure of health to be well adjusted to a profoundly sick society.”

[yard2010]

I member! Remember when dissatisfied women needing an orgasm was a mental disorder?

https://pmc.ncbi.nlm.nih.gov/articles/PMC3480686/

> Fate, which takes away healthy, free, young people, never pardoned me once. It has let me live all this time, quite lucid, but closed up in here ... since I was ten years old .... eighty years in psychiatric hospital for a headache

Take modern medicine with a grain of salt.

[plandis]

What is your point?

Surely you’re not trying to draw some conclusion between an entire countries modern day medical field and a theory a person proposed in the 1800s, right?

[sedivy94]

Hi, not the parent poster here. I believe the argument being made is that diagnostic criteria, and diagnoses themselves, can be shaped by cultural norms. As the Overton window shifts, so do the thoughts and behaviors that we deem pathological.

[lutusp]

> Surely you’re not trying to draw some conclusion between an entire countries modern day medical field and a theory a person proposed in the 1800s, right?

That would depend on whether anything has changed since the 1800s. But that's very clearly not so -- consider that recovered memory therapy (https://en.wikipedia.org/wiki/Recovered-memory_therapy), based on as much science as drapetomania, was practiced in the 1990s, and still has adherents today.

Also, for human psychology to be regarded as a medical field, it would have to be based in science. But human psychology studies the mind, therefore by definition it's not based in science.

[cyanydeez]

unfortunately, what seems to be driving modern disorder diagnosis is what gets issurance to pay. That's why autism is now a spectrum.

[eddythompson80]

It’s the other way around AFAIK. Insurance pays for what’s categorized as a disorder by the DSM. Or did I misunderstand your statement?

[sophacles]

And atoms used to be the smallest division of matter. Then we learned about smaller things.

Understanding changes as we do more research into a thing.

[cyanydeez]

No. This is lumping, not splitting

Im not arguing people diagnosed with autism spectrum disorder shouldnt get benefits.

Its that the spectrum isnt as related enough that insividual disorders would make more sense. But that would require getting the health insurance industry to do more adjustments.

[reorder9695]

How else would you do it? Unlike an e.g. viral infection there is no positive test you can look at. Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment. I don't think you can be totally objective about this, and you get into things like if i.e. autism is mild is it a disorder? It's pretty clear to me it should be considered as such after a certain level of severity, but maybe it shouldn't always be if it has minimal impact on the person

[aleph_minus_one]

> Generally a disorder is considered something that significantly impacts someone's life, getting in the way of things like working, social life, life enjoyment.

With the same argument, we could arguue that working and social life are getting in the way how I am, thus working and social life should be considered disorders.

[hn_throwaway_99]

These reductio ad absurdum arguments are wholly unpersuasive. The fact that there are some debatable gray areas in the DSMs seems like poor reasoning to throw the baby out with the bathwater. E.g. things like schizophrenia, OCD, major depressive disorder, etc. are so highly disruptive to the individuals involved that arguing that they shouldn't be disorders (or, contrary, that anything else is a disorder) feels like an unhelpful semantic game.

[dns_snek]

A ridiculous argument. Most often a disorder will impact activities you enjoy just as much as those you don't. Very broadly speaking, if all of your symptoms go away when you get home from work then you don't have a disorder, just a demanding, stressful job. That's certainly true for disorders like ADHD and ASD that are under attack these days.

[ben_sisko]

Sounds like you need to read better books Bromaster General!

[aleph_minus_one]

> Sounds like you need to read better books Bromaster General!

I don't get this reference (that is likely rooted in US popular culture).

[brooke2k]

A "disorder" is just a collection of symptoms that have been empirically shown to benefit from certain treatments. If someone doesn't think they have those symptoms then they can just not seek a diagnosis or treatment. Nobody is forcing a diagnosis on somebody who doesn't want it.

[bjornsing]

If you look into the history of psychiatry I think you’ll find quite a lot of examples when diagnosis and treatment was forced on people who didn’t want it. It’s not hard to find contemporary such examples either.

[brooke2k]

Yes, that did unfortunately happen in the history of psychiatry. I am talking about modern American psychiatric practices (say, the last 10-20 years).

If the proposition here is that mental health disorders are fabricated maliciously in order to sell more medication or enforce some sort of social order, then I don't see how the very rare court-ordered enforcement of short-term stays at psychiatric institutions could be the mechanism for that.

The vast majority of people in the US who receive psychiatric care do so voluntarily, because they experience real symptoms that really affect their life, for which they need real treatment.

[creata]

> The vast majority of people in the US who receive psychiatric care do so voluntarily

That's true, but that's not what the parent comment claimed. They didn't say a majority receive psychiatric care involuntarily, they said it's not hard to find examples who receive it involuntarily, and that's true. Lots of people are forced to take psychiatric medication right now, in developed countries including the US.

[amiga386]

> Lots of people are forced to take psychiatric medication right now, in developed countries including the US.

Just as an example, in the UK the verb "to section" is shorthand for "to commit to involuntary confinement in hospital under the legal authority of one or more sections of the Mental Health Act"

https://www.mind.org.uk/information-support/legal-rights/sec...

For example, you can be detained for up to 6 months under Section 3, if all four of these conditions are met:

1. you have a mental disorder

2. you need to be detained for your own health or safety or for the protection of other people

3. doctors agree that appropriate treatment is available for you

4. treatment can't be given unless you are detained in hospital

[s5300]

>> Nobody is forcing a diagnosis on somebody who doesn't want it.

Ahh, you sweet summer child

Tell that to all multiple sclerosis patients that were tortured by psych departments of hospitals before (and after) the MRI machine was created.

Tell that to sleep apnea patients (especially the women, especially especially the younger thinner women in whom they say “it cannot happen to”) that are given a psych diagnoses for seeking treatment for symptoms before sleep disordered breathing issues are ever even brought into question.

The main problem is that DSM diagnoses are indeed forced on people. Usually highly incorrectly, too.

[gruez]

>What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm

What's the alternative then? What would "empirically" determining what a "disorder" is look like?

>…by Americans

Most of the world outside of the US uses the ICD, not the DSM.

[NikolaNovak]

Agreeing that social science is harder than most, I see these definitions as “circle around a set of presentations / symptoms / behaviours “. As somebody who has several circles around them, it doesn’t bother me overly. Historical enforced procedures / incarcerations did, but I understand value of “common language”. In a wildly different area that may or may not resonate with HN, I find similar value in PMP or ITIL - it’s not the One True Way, it is not necessarily a permanent scientific best approach… but it does give people of today a way to communicate with each other across domains, companies, cultures and experiences .

[epgui]

> The DSM in many ways represents the worst of so-called social science.

No. You need to read the thing.

The DSM only aims to be a tool to help standardize communication of often nebulous and otherwise ill-defined entities. It says so in the introductory pages.

People shouldn’t treat it like a biology textbook, it’s a self-described ontology at most.

[sundarurfriend]

But people do. Psychology courses do, with a similar "tool to help standardize communication" line recited robotically and then practically ignored. Most practicing psychologists do as well, to only a somewhat lesser degree.

You cannot have an authoritative textbook proscribing definitions, and then expect people to treat them as just "a self-described ontology" with all the nuances and caveats around that just because it says so somewhere in the introduction. Psychology of all fields should know that.

[epgui]

I’ve had a bunch of neuro/psycho classes and this was always well understood.

This stuff is complicated. People are going to get it wrong. That sucks.

But if you’re going to judge the book, judge it by how it presents itself, don’t judge it by how a third party misrepresents it.

[aleph_minus_one]

> But if you’re going to judge the book, judge it by how it presents itself, don’t judge it by how a third party misrepresents it.

As long as the boards don't go after the shrinks who "misrepresent" the DSM, I would claim that this misrepresentation is systemic of (and possibly even intended by) the psycho-industrial complex.

[epgui]

Boards are expected to “go after” professionals who do not provide a certain standard of care, but that has very little (if anything) to do with the DSM.

I think this comment just reinforces a misunderstanding of what the DSM actually is.

[dotancohen]

If the DSM merely described sets of symptoms and gave them names, I'd buy that. But by also mentioning (e.g. suggesting) specific treatments, the book is used as a prescription tool, not just a diagnostic tool.

  > But if you’re going to judge the book, judge it by how it presents itself

Quite so. I just as we judge people by their actions, not their words, I judge the DSM by how it's actual content is structured, not by its introductory quip.

[autoexec]

Why shouldn't it include a bunch of treatments if they've been shown to be beneficial? How would it be better if people had to go to some other book and look up those same conditions using the names listed in the DSM in order to find out which treatments might be useful?

Doctors (at least the good ones) aren't usually going in blind and just doing whatever the DSM tell them to as if they were following a flowchart or checklist. The DSM (which I'm not even fully defending here, I personally it feel has all kinds of problems) is just a guide. It's not the only tool in a doctor's arsenal and they aren't obligated to follow it.

[dotancohen]

  > Why shouldn't it include a bunch of treatments if they've been shown to be beneficial?

It most certainly should, I'm not saying it shouldn't. My argument is that, by suggesting specific treatments, the DSM is a prescription tool. Not merely a diagnostic tool.

[epgui]

Oftentimes in psychiatry the treatments are just as important as anything else in establishing a diagnosis.

There’s a well-known concept of “diagnosis by treatment” because unfortunately that’s often the best we can do in practice. It sounds backwards, and yeah, it is backwards, but oftentimes it’s the best we’ve got.

At the same time you want treatments and clinical presentations to be somewhat coherent, and you don’t want practitioners going totally rogue and deviating from the standard of care in a way that could harm people, so yeah the conditions and their potential treatments are associated.

Most discussion of treatments in the DSM are various forms of therapy. Most pharmaceutical treatments that are mentioned are about broad classes of medications, and they’re all old drugs with generics on the market. It’s not a book you consult for pharma info.

[dotancohen]

I'm not disagreeing with anything you say, although I did not know the concept of diagnosis by treatment is actually formerly recognised. That is exactly why the DSM is a prescription tool, not merely a diagnostic tool as reading of the introductory text would have one believe.

[autoexec]

> What counts as a “disorder” is often not based on empirical evidence but on what is determined as undesirable, maladaptive, or outside the social norm…by Americans.

I've seen that used before to dismiss the severity of conditions like autism and especially ADHD. It's often coming from a well-meaning place, and sometimes it's just a comforting story people tell themselves in order to not feel as deficient ("The problem isn't me, it's the system!").

It's also absolutely true that the demands society places on all of us are unnatural and often excessive, but the fact is that even absent all external expectations some people with mental illness will be unable to accomplish what they themselves want and should be able to accomplish.

Even the most utopian, accepting, accommodating society it wouldn't be enough to make up for some people's inability to function.

I feel the same about a lot of the "super power" talk when it comes to mental illness. There are advantages and disadvantages to just about anything, but on the whole conditions like ADHD or autism tend to do way more harm than good.

[mcslambley]

“Empirical evidence” and “what is determined as undesirable, maladaptive, or outside the social norm” are not mutually exclusive.

[birn559]

My inability of being in nature without a feeling of being tortured comes from my brain not working correctly and it's not "undesired behavior". Luckily, my ADHD meds are able to fix that.

[riazrizvi]

Without a clear and agreed behavioral model, I don’t see how disorders can be properly defined.

[ben_sisko]

The exercise and food science people are the worst of social science buddy. Or just “social” something, because it’s not science. “Science-based” always makes me laugh.

The DSM only matters if somebody is actively seeking treatment for something that they have a problem with in their own situation. So what’s in there is totally irrelevant for the public at large. It’s only if somebody shows up and says there’s something going on that they don’t like. It’s really just billing codes, man. The reality is far different anyway, and it just gets distilled down to these primitive codes.

[naveensundar]

I think this is not a valid criticism.

By this criteria, you can then say many other non-psych conditions are not disorders.

What classifies as a disorder other than making life worse for someone?

There is no universal book given by a holy entity that we can read to classify something as normal or a disorder.

Why do we have arbitrary cutoffs for cholesterol, blood sugar, blood pressure, etc?