DSM-5

This was a fascinating Wired article conveying some of the most common criticisms of the proposed DSM-5: "To critics, the greatest liability of the DSM-5 process is precisely this disconnect between its ambition on one hand and the current state of the science on the other. On the authority of doctors and psychologists' dirty little secret:

The authority of any doctor depends on their ability to name a patient’s suffering. For patients to accept a diagnosis, they must believe that doctors know—in the same way that physicists know about gravity or biologists about mitosis—that their disease exists and that they have it. But this kind of certainty has eluded psychiatry, and every fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can’t rigorously differentiate illness from everyday suffering. This is why, as one psychiatrist wrote after the APA voted homosexuality out of the DSM, “there is a terrible sense of shame among psychiatrists, always wanting to show that our diagnoses are as good as the scientific ones used in real medicine.”

The solution and the problem that the solution created:

Since 1980, when the DSM-III was published, psychiatrists have tried to solve this problem by using what is called descriptive diagnosis: a checklist approach, whereby illnesses are defined wholly by the symptoms patients present. The main virtue of descriptive psychiatry is that it doesn’t rely on unprovable notions about the nature and causes of mental illness, as the Freudian theories behind all those “neuroses” had done. Two doctors who observe a patient carefully and consult the DSM’s criteria lists usually won’t disagree on the diagnosis—something that was embarrassingly common before 1980. But descriptive psychiatry also has a major problem: Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have “major depression,” no matter your circumstances or your own perception of your troubles. “No one should be proud that we have a descriptive system,” Frances tells me. “The fact that we do only reveals our limitations.” Instead of curing the profession’s own malady, descriptive psychiatry has just covered it up.

What is at stake:

At stake in the fight between Frances and the APA is more than professional turf, more than careers and reputations, more than the $6.5 million in sales that the DSM averages each year. The book is the basis of psychiatrists’ authority to pronounce upon our mental health, to command health care dollars from insurance companies for treatment and from government agencies for research. It is as important to psychiatrists as the Constitution is to the US government or the Bible is to Christians. Outside the profession, too, the DSM rules, serving as the authoritative text for psychologists, social workers, and other mental health workers; it is invoked by lawyers in arguing over the culpability of criminal defendants and by parents seeking school services for their children. If, as Frances warns, the new volume is an “absolute disaster,” it could cause a seismic shift in the way mental health care is practiced in this country. It could cause the APA to lose its franchise on our psychic suffering, the naming rights to our pain.

The future:

Some mental health researchers are convinced that the DSM might soon be completely revolutionized or even rendered obsolete. In recent years, the National Institute of Mental Health has launched an effort to transform psychiatry into what its director, Thomas Insel, calls clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses. The institute says it’s “agnostic” on the subject of whether, or how, this process would create new definitions of illnesses, but it seems poised to abandon the reigning DSM approach. “Our resources are more likely to be invested in a program to transform diagnosis by 2020,” Insel says, “rather than modifying the current paradigm.”

Crime pays

A reader sent this link to an article of the 10 criminals who "made a killing" financially, just in case people were wondering whether crime does or does not pay. Interestingly the list includes basically only CEOs and drug dealers.

Let's talk about S, baby (part 2)

My response:

If your friend has been outting himself to you as a sociopath then he has really done all of your work for you. Now you just continue the joke with him to see what else he says -- e.g. when he mentions something about sociopathy or if he exhibits some of the traits, you could make a small little observation or joke like "that's just the sociopathy talking."

I wouldn't tell him anything about what you know. He will be able to discern it eventually, but it is best for you and your own self interest to watch him for a little while knowing what you know but without him knowing what you know. You need to do your own method of datamining on him because as much as you read, there is still so much to learn, particularly about things specific to him.

After you are sure that you are committed to being supportive to him despite who he is, then you can start to be more explicit about things, still joking but painting them in a positive manner. For instance, maybe when he does something positive or particularly cunning or powerful you can say something like "go go super sociopath," or something similar to make it sound like his sociopathy is some sort of super power and not anything to be ashamed of.

But be careful before you make any commitments to him, because it sounds like you are the type to keep your commitments and you may think you know him and can stomach him right now, but I've had friends try before and fail and it is much worse than if they had not tried at all (see the recent post on rejection).

Let's talk about S, baby (part 1)

From a reader:

A young man who I consider to be a close friend of mine (as well as an occasional “lover,” if you will) began to - seemingly jokingly - assert that he was a sociopath. I laughed, gave an unserious “right” in response, and thought virtually nothing of the matter until I researched the topic earlier this week on no more than a trivial whim. My preliminary discoveries being what they were, my light-hearted curiosity quickly escalated to full-blown panic. Every piece of his character seemed to fit so perfectly, and every article, blog, and comment seemed to conclude with a “run for your life!” mentality. While alarmed and distressed, I am not a runner, and thankfully continued my investigation until it led me to your blog.

I’ll start with some background information on my friend. He is extremely intelligent, and thinks in ways that frequently cause my mind to ache or attempt to shut down completely. He can memorize entire conversations, scenes, large portions of books, and who knows what else. He is also extremely contradictory. He’ll act as the life of the party or show up at my door every day for a week, then retreat completely to his basement for days or weeks at a time, explaining that he is totally incapable of dealing with people and society. After knowing him for a few months, I toyed with ideas of bipolarity and even Asperger’s, as he mentioned once that he believed his father might suffer from the syndrome. But a year of further interaction and observation later, these explanations just don’t quite cut it. The following are characteristics he has displayed or openly explained to me:

• He claims to hate humanity – or at least humanity as we are now, and will often toy with people, setting up mind games and manipulating people around him in order to observe their responses. He says he no longer believes in truth after witnessing the deceit that man is capable of for personal gain. He’s even said that he thinks we are all sociopaths to some degree. He can charm his way into or out of any situation. He is reckless. He drives too fast, laughs too loud, and eats without tasting. He has told me that he cannot feel and that he does not believe in empathy. He does not cry; he doesn’t get hurt; he doesn’t understand these reactions and emotions.
• He’s asked me on numerous occasions what it feels like to cry. He’s seen me cry on several occasions due to pain he inflicted and admitted that he cannot comprehend why I feel the way I do. He says he cares for people, but not in the same way that everyone else does. He doesn’t miss people. He would not grieve were one of his family members to die.
• He was ostracized in elementary and middle school. He didn’t know how to interact with other children and acted out constantly in school. He deliberately enraged teachers and other authority figures with tricks and mind games. In high school and college, he says he learned how to appropriately interact with others through observation, and engages in interpersonal play out of general interest and necessity.
• He is fascinated by music and film, claiming that these mediums allow him to feel more “real” than real life. Sometimes he believes himself a "real" human; sometimes he does not.
• He’s deeply hurt almost everyone who has been close to him for an extended period of time, and appears to feel no remorse, yet is noticeably distressed at the idea of being seen as a “monster.” When drunk, I have witnessed incredible bouts of rage aimed at the world, himself, and every mailbox in between. He tried to kill himself two years ago, but failed (whether miraculously or intentionally, I’m unsure).

So after all this, my question for you is what can I do? How do I confront him without it coming off as an attack or negative accusation? If he truly is a sociopath, I want him to know that I can accept it, can accept him, and that I will not think of him as a heartless monster; that I will try to understand him as best I can, and believe we both may have something to gain through mutual understanding, respect, and continued exploration.

But I’m afraid that he has observed so much deceit within humans that he simply will not believe me. He won’t trust it. I want him to know that he doesn’t need to play the games or wear the masks with me that he does with everyone else. That if he will communicate his thoughts to me, no matter how far from my own, I will accept them and offer what I can in return. Do you think this is possible?

Narcissist?

A reader writes:

I think I may possibly be a narcissist. I found your website, and it opened my eyes and has been more informative than you can imagine.

Even from when I was a child, I have had strong impulses to hurt people and animals. Its just random, there is no reason for it really, but I still find myself wanting to beat someones head in with a bat. And it scares me sometimes, because I'm pretty sure that isn't normal.

I would have strange outbursts of rage, and always play my parents against each other when trying to get the things I wanted. They took me to a therapist suspecting that I had anger issues, but all the therapist concluded was that I was extremely manipulative. When I found out what it meant, I felt empowered, or smug, as if I had something that I could easily use against my parents or other people to get what I wanted. Before that though, I had no idea I was being manipulative, it was just a natural thing, you know? Just part of who I was. It was just my natural way of being. After the therapist though, I had a name for it.

And I realize that I am still, I get a satisfaction out of playing with people's emotions and using them in whatever way suits me, even if it hurts them in the process. I just love it, and to me it is fun. I know its not right, but I need to do it.

I am a compulsive liar, I lie for no reason. I cant seem to stop, even if the lie has no effect on anything. I hate the world around me and am constantly disgusted with people, and consider myself apart from them. Better, and different in the fact that I am deeper than them and have a superior sense of understanding things, and that they will never understand anything I tell them.

However I have no criminal record whatsoever, and have no authority problems. Not that i dont want to, sometimes I want to compulsively kill people or hurt someone, but I realize that if I did that I would just be put in jail and my life as I know it would come to an end. I understand that I have to follow the rules just like everyone else, and so I do.

I believe I do have some empathy, though it seems to come and go. And my empathy is very limited. The only people I consider my equals are those I like and find 'worthy'.

I have read through a lot of the information on your site, on blogs, etc. But I just dont know what to think or consider myself. When I read stories, or personal experiences from sociopaths or narcissists I feel like its me speaking. It just fits. I'm scared to tell anyone, in that they may think I am making this up, and honestly I don't want a label anyways. All I want is to know who I am, and to have a reason or a name, or even people to talk to who understand me. I cannot tell you how good it feels to get this out, and to speak to someone who might for once listen, and I would be so grateful if you could even shed a sliver of light on my situation.