Social judgments in psychiatric diagnosis

Around the time I was finishing medical school I published a short essay on subjectivity in psychiatric assessment.  The American Psychiatric Association had released the third edition of its Diagnostic and Statistical Manual just a few years before.  When it came out in 1980, DSM-III was a revolutionary update:  It provided specific criteria for diagnosing disorders, not the narrative descriptions of the previous editions.  In my essay I pointed out that the new, precise-sounding criteria still included social judgments.  For example, “inappropriate affect” was a criterion for schizophrenia, even though inappropriateness is assessed in relation to a given situation, depends on cultural norms, and is a judgment call.  My point was not that we should avoid social judgments in psychiatric assessment, but that they are inevitable, whether expressed in narrative descriptions or in numbered lists of diagnostic criteria.

Fast forward 20+ years.  The current (11/10/08) issue of The New Yorker features an article by John Seabrook called “Suffering Souls: The search for the roots of psychopathy.” It presents an overview of “the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population….”  Seabrook notes that psychopathy is not a diagnosis in the current DSM-IV; the more general antisocial personality disorder subsumes it.  Much of the article revolves around brain imaging studies using fMRI to discern which parts of the brain are over- or under-utilized in psychopaths versus normals.

Functional imaging like fMRI has grown huge in psychiatric and brain research, almost to the point of becoming a fad in some areas.  Everyone wants to know what parts of the brain “light up” in different disorders.  Psychopathy is no exception, and such studies may uncover crucial findings about the condition.  More interesting to me, though, is that psychopathy is defined almost wholly by social judgment.  It causes no distress in the person who has it, and generates virtually no clinical signs outside the social sphere.

Early in the article Seabrook says the psychopath’s main defect is “a total lack of empathy and remorse.”  That was the way I learned it, too.  Such a definition categorically separates psychopaths from normals in a manner that is non-situational, relatively free of cultural bias, and avoids nuanced judgment calls.  However, it is also the last we hear of it.  The rest of the article takes a dimensional, matter-of-degree approach.  First presented is the well-known Psychopathy Checklist, or PCL-R, developed by Canadian psychologist Robert Hare.  The PCL-R interviewer scores the subject on 20 items, including irresponsibility, parasitic life style, lack of empathy, and shallow emotions.  Most researchers agree that psychopathy is present above a certain threshold score.  While the PCL-R has good face validity, its use to assess psychopathy requires judgment calls, taking the situation and culture into account.  As mentioned above, this is inevitable in much of psychiatry; we just need to be careful about it.

The danger surfaces later in the article.  Seabrook is driving with Robert Hare, who sees another driver run a red light.  Hare remarks: “‘Now, that man might be a psychopath.  That was psychopathic behavior certainly — to put others in the intersection in danger in order to realize your own goals.'”  Seabrook observes that this kind of behavior is commonplace, and “can make it possible to see psychopaths everywhere or nowhere.”

The pejorative association of psychopathy with serial murders and other horrible crimes underscores the liability of seeing disorders “everywhere or nowhere.”  In the last 25 years the DSM list of official psychiatric disorders has mushroomed.  As disorders are codified — and importantly, as medications are marketed for them — more and more people receive diagnoses.  What was once shyness has become social anxiety disorder, treatable with SSRI antidepressants.  Poor concentration and an inability to sit still has become ADHD, treatable with stimulants.  Social-context judgments (and financial incentives) grease the wheels of “diagnosis creep.

Social judgments in psychiatric assessment are inevitable, but that does not mean we can be casual about them.  On the contrary, their very subjectivity argues for closer scrutiny and care, as the pitfalls resulting from bias and intellectual laziness are grave.  If every personality quirk is a disorder, then psychiatric diagnosis loses meaning.  Worse, the parameters of normality narrow.  Tolerance of difference retreats in step with “diagnosis creep.”

Psychopathy, like schizophrenia, are useful concepts.  Let’s keep them that way, despite the shifting sands of the social milieu.

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