The Fallacies of Psychological Diagnosis

As you may have heard, the American Psychiatric Association is in the midst of a revision to its Diagnostic and Statistical Manual of Mental Disorders, used to identify different mental illnesses and assign diagnostic labels to patients.  This newest edition, the DSM-V, will be published some time in 2013.   Among the more controversial changes is the elimination of five of the 10 personality disorders currently listed, the best known of which is Narcissistic Personality Disorder (NPD).

This revision seeks to move diagnosis toward a greater emphasis on descriptive traits, based on the undeniable fact that individuals diagnosed with one personality disorder often demonstrate traits associated with another.  As many clinicians have pointed out, the personality disorders exist along a spectrum.  I suppose this refinement in the DSM is a step in the right direction as it appears to treat people a bit more like individuals than categories, but I have a more fundamental problem with the idea of assigning diagnostic labels in the first place.

The fundamental assumption behind the DSM is that its categories of mental illness, with their official code numbers, actually correspond to a discrete syndrome exhibited by real people; in this sense, it is meant to be the psychological counterpart of the International Classification of Diseases 9 (ICD-9) used by physicians to diagnose and label physical illness.  In theory, applying the DSM-IV label Narcissistic Personality Disorder should carry the same weight and have as much scientific validity as an ICD-9 code for, say, diabetes.  The impending elimination of NPD from the DSM-V proves that such an analogy is fallacious.   Can you imagine if the American Medical Association suddenly announced it intended to eliminate diabetes from the ICD-9?
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Celebrity and Romantic Love: “Meaning” in the Modern World

In our modern culture, a huge number of people seem to derive a sense of meaning in their lives through the worship of celebrity (combined with a longing to achieve personal notoriety) and/or the pursuit of idealized romantic love.  I’ve discussed these issues in my earlier posts on celebrities and love junkies; my good friend Marla Estes has also done extensive work on the subject of romantic love in the seminars she teaches.  I’d like to enlarge those ideas into a discussion of personal values and how we derive a sense of purpose in our lives.

You might have heard about Jake Halpern’s book Fame Junkies.  In a survey of several hundred middle-school students in upstate New York, Halpern found that just under 50 percent would prefer to work as a personal assistant to a celebrity over being a university president, corporate CEO, Navy Seal or U.S. Senator.  These students valued mere proximity to a celebrity over other kinds of prestigious work.  Another poll conducted by the Pew Research Center found that the vast majority of 18-25 year-olds surveyed in 2007 listed fortune and fame as the top two goals for their generation.

I find these results discouraging but they come as no surprise.  Grocery store news racks, the ones at the check-out lines, mostly hold magazines with movie and TV stars on their covers.  The shopping public seems to have an inexhaustible interest in famous people and their love lives, even though such stories concern the same mundane events that vast numbers of Americans personally experience:  dating, starry-eyed romance that leads to an idealized wedding, followed by disillusionment, infidelity and broken families.  I’ll bet another survey would show that most people would prefer to be a wealthy celebrity going through a painful divorce than a schoolteacher basically satisfied with his or her marriage.  Most people feel that to be famous gives their lives meaning and rescues it from the uninspired realm of ordinary life.

TV reality shows give the average man or woman a chance to participate in that world of celebrity, if only for a brief time.  I believe this is why so many people are willing to expose the most personal and painful details of their lives on nationally-televised shows like Dr. Phil or Jerry Springer.  Quaint notions of privacy or appropriate shame have no force when overpowered by the lure of notoriety.  Maybe my empty life is a total mess, my marriage a shambles and my family alienated from me, but as long as I can be on television, it will nonetheless mean something!
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Art and the Dread of Experience

Over the years, I’ve worked with a number of artists — musicians, a choreographer, several writers — and dealt with various types of artistic inhibition such as writer’s block.  In our work together, my clients and I  struggled with issues that might be familiar to you:  perfectionism, grandiosity of the type described in my post on self-criticism, as well as the self-envy that may lie behind fear of success. With several of my clients, I came to understand another such difficulty in making art, where the original inspiration or emotional charge behind the work of art is killed off in the process of creation.

In an earlier post on anxiety attacks and disorders, I introduced the concept of mind as a container for emotional experience; I discussed how people with “insufficient mind” — that is, an inability to contain and manage their emotional experience — often feel terrified that strong feelings will overwhelm and annihilate them.  Several of the artists in my practice fit this description.  One of them was prone to anxiety attacks and states of disintegration; another led a very controlled life, without much human emotional involvement; a third showed symptoms of autism and often tried to shut out a world that stirred up such terrifying emotions.  These difficulties also affected their creative processes.

Over time, we came to think of the work of art — be it a choreographic work, a song or a piece of fiction — as a sort of container for their emotional experience.  It’s how I think about art in general:  great works of art contain and express profound emotional experiences; optimally, the shape of that container (the individual and unique painting, novel, symphony, etc.) bears an organic relationship to what is contained, adapting its shape to the needs of authentic emotional expression.  I hope that doesn’t sound too abstract; as a clinician, I have found it an incredibly helpful way to think about my artist-clients.  The artist works upon his or her “insights” and tries to create a uniquely powerful work of art that will convey powerful emotion (basic human truths) to an audience.

With several of my clients, they started off with a powerful feeling or insight but in the process of creating their work of art, deadened it.  The art they produced (in their own view, not mine) lacked “depth” or “dimension”:  dance works felt “constipated”, their performers trapped in choreography with constricted movement and little emotion; songs seemed simplistic and boring, without true feeling; characters appeared “flat” and “two-dimensional”.  In our culture, we frequently use these exact critical terms:  lack of depth, flat characters, two-dimensional stories, etc.  A vital artistic container has three dimensions and its own sort of life force; it has an interior and a surface or “skin” with which we, as audience, can interact.

Unsuccessful works of art have little dimension.  Rather than containing and conveying powerful emotion, they stifle it.  The artist who is terrified of intense emotion may mis-use his or her art form, employing it to flatten feelings instead of expressing them.  For that reason, the works of art they produce will leave an audience feeling “cold”, indifferent or bored.  In short, rather than conveying profound and intense human truths, such art works seek to deny them.

Recently, one of my clients (an aspiring and frustrated writer) brought in a dream that perfectly illustrated this process.  She was treading water in a pond along with some “cowboys”.  The pond felt like a whirlpool and they were all in danger of being sucked down into it.  The only way to save themselves — that is, to keep from drowning — was to tell one another non-stop stories while treading water.  At the same time, each of them had to hold onto a piece of raw meat that had been vacuum-sealed in plastic.

The cowboys are linked to the Wild West, a frightening way of life without the restraining influence of law and civilization.  Raw meat connects to raw emotion.  The dream shows how my client is terrified of her own raw emotional experience; in order to save herself from being overwhelmed by that experience, she resorts to “art” (telling stories) as a defense.  In the process, she shrink-wraps her experience and makes it safe, no longer raw and vital but hygienically processed, like something you might find in a supermarket meat case.

Finding Your Own Way:

I know that a number of visitors to this site are artists; I’d welcome your input on this subject.  What sort of artistic inhibitions have you struggled with?  Does this description in any way resonate with your own experience?  What about your view of other artists and their work?

As for the rest of us, we might begin with our relation to different art forms and how they affect us.  Think of a movie you found boring and ask yourself why.  Was it because the characters were flat, the story lacking in dimension?  Movies that portray extremely black-and-white characters often leave me cold because they strike me as a denial of a basic truth, that humans are a mixture of good and bad, each of us struggling with unavoidable ambivalence. What about novels you put aside and never finished?  Was it because they failed to engage your emotions?  Did they seem flat and lacking in dimension?

Many of us have artistic urges and never manage to fulfill them.  Maybe it’s because we lack time and self-discipline; maybe it’s because we don’t have the patience to master the needed skill.  Another possible explanation, suggested by this post, is that we grow bored with the process, bored with our own creations, and abandon them.  Sometimes people take up a “hobby”, an artistic endeavor that holds meaning, and in the process somehow render the experience meaningless to them; often it’s because they simply can’t sustain intense emotional involvement with themselves and their art form.

A Portrait of Narcissistic Personality Disorder in ‘The Social Network’ (2010)

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Throughout The Social Network, Mark Zuckerberg demonstrates most of the traits associated with what the DSM-IV calls “Narcissistic Personality Disorder.”  If you’ve spent much time on my site, you’ll have gathered that I’m no fan of diagnosis.  I don’t want to end my discussion of the film before I’ve even begun by affixing a label to this character; instead, I’d like to use The Social Network as a way to approach a cluster of psychological traits that often go together.  Sometimes you see them in the bipolar disorders; or you might find them displayed by someone who’d receive a diagnosis of Borderline Personality Disorder instead.  In truth, the so-called personality disorders exist along a spectrum, nobody fitting neatly into any single diagnostic category, but I’ll use the DSM-IV criteria for Narcissistic Personality Disorder as a basis for my discussion.  I’ll invert the order of list and end with the earlier criteria since they raise some interesting and difficult questions.

According to the DSM-IV, you need to display at least five of these qualities to meet the diagnostic threshold.

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Compassion, Altruism and the True Spirit of Generosity

I have an ongoing debate with my oldest son about pure altruism and whether it actually exists.  He believes that nobody ever acts in a purely selfless way; part of the motivation for altruistic behavior, he argues, is to feel good about oneself as a person.  If you get some reward from the supposedly altruistic act then it can’t be purely selfless.

I go back and forth on my position.  “You haven’t had children yet,” I once told him.  “If I had to choose between us, I’d die for you.”  This was a cheap and sentimental argument, trying to use my supposedly self-sacrificial feelings as his father to win the debate.  He would have none of it. “That’s just because you wouldn’t be able to live with yourself otherwise.”  While that isn’t the only reason, of course not, it is definitely a large part of it.  This question isn’t finally settled in my mind but I think my son is winning the debate. With the Christmas holiday approaching — “the season of giving” — I’ve been thinking about compassion and self-sacrifice, and what motivates people to engage in apparently altruistic behavior.

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