On the Diagnostical and Statistical Manual of Mental Disorders: Pangloss versus Ice-Bitch

“Welcome all ye listeners, today we are discussing the new ‘Diagnostical and Statistical Manual of Mental Disorders’, colloquially known as DSM-5, the sequel to the hugely influential and popular DSM-4 that really put the American Psychiatric Association on the map. We are joined by Professor Pangloss, streight from Voltaire’s Candide, who will be ringing its praises, and Professor Ice-Bitch, streight from the Chicago school of Economics, who opposes its very existence. I am your mediator, Paul Doubtful. Don’t forget to cast your votes online after the show so we can see who was the most persuasive.

Welcome, Professors Pangloss and Ice-Bitch!

Pangloss/Ice-Bitch: thank you, Paul.

Paul Doubtful: can I ask each of you to give your brief opinion about the DMS-5 in no more than 100 words, starting with Professor Pangloss?

Pangloss: my pleasure, Paul. The DSM-5 comes as a great relief to the large number of people in our society who feel they are not quite the same as others but whose needs have previously been neglected in the absence of a deeper understanding of their particular mental health issues. With the DSM-5 we are set to enter an age in which a large part of our society, perhaps even the majority, can receive the attention and understanding they need to be valuable members of our society. It equips local health practitioners with particular treatment plans and diagnostic tools.

Ice-Bitch: also happy to oblige, Paul. The DSM-5 will mainly serve to further medicalise our societies such that everything that used to be in the realm of personal responsibility becomes a medical problem, to be milked by a medical industry, and absconding individuals from the responsibility to find their own ways to deal with their issues. Rather than liberating the mentally less able, it will end up making a victim of large parts of the population, many of whom could have been proud and self-reliant adults, instead leading them into apathy and complacency, with the state penalising the successful to subsidise a nanny-state for the unsuccessful.

Paul Doubtful: thank you, that’s very clear. We’re in for a real debate here! Let’s get into particulars. Can I first of all get a quick answer from both of you as to whether DSM-5 will increase the number of people diagnosed with a mental disorder even in the absence of real changes in mental functioning.

Ice-Bitch\Pangloss: of course.

Paul Doubtful: ah, so we are not going to disagree about the immediate consequences of this thing or how to read statistics. Thank god. Ok then, let’s discuss the change in the definition of a mental health disorder between DSM-4 and DSM-5. It has gone from a ‘pervasive pattern’ of ‘inner experience and behaviour’ that is ‘deviant from a cultural norm’ to an ‘adaptive failure’ and a ‘failure to develop effective interpersonal functioning’. What do you make of this?

Ice-Bitch: you are just looking at exactly the same meaning, but more complicated words. You get this often when rent-seeking industries have discovered a weak population whose needs it pretends to champion: part of the trick of arguing for more subsidies is to keep the skeptical audience on their toes regarding the terminology. As soon as that audience reveals that they are not quite ‘au fait’ with the new words, you denounce them as ignorant malicious bigots who clearly should not be involved in the discussion. It’s thus a marketing gimmick meant to silence debate.

Pangloss: I actually wouldn’t deny most of what Ice-Bitch said, but deem this irrelevant. Of course there is marketing, but society gets marketing from all corners, nevertheless having to make its choice anyway. What I like about the new definition is the recognition that we are really looking at interpersonal functioning rather than inner experiences. It puts the relation of the mentally unhealthy with the rest of society centre-stage and thus no longer carries an implicit judgment on what to make of the inner lives of people, which will help reduce the stigma attached to mental illnesses. If you like, it’s a similar development as we have seen in the literature on poverty where we also started out just looking at issues of income and feelings, but have in recent decades become aware that the really important aspects are capabilities for functioning, leading to things like the Human Development Indicator as a measure of progress rather than just income. Of course, in the longer-run one gets to re-discover that functioning too is ultimately all about an inner experience, but I think that there is an element of educating the audience in these progressions of definitions and that we hence might see more recognition of inner-feelings, like happiness, in the DSM-6 definition.

Ice-Bitch: sure, but this too is itself an example of not really treating the audience like rational adults in that one withholds from them what goes on in the back of one’s mind with these definitions. Like the supposed Good Sheppard you are making judgments about what the audience wants to hear, how much they can understand, hiding some of the underlying complexities and intentions from public view.

Pangloss: you say that like it’s bad thing. I am perfectly fine with the idea that not every member of every audience has to be explicitly told everything. If members of the public would really be interested, they are perfectly free to look up the academic debates in learned journals that have all these issues discussed. The fact that people don’t do this should tell you they don’t really care.

Ice-Bitch: not at all, it’s a matter of information intermediaries. The public uses things like the DSM-5 as an authoritative signal of what is known in the underlying literature. Deliberate hiding of complexities and hidden agendas simply increase the cost of signalling, leading to inefficiency.

Pangloss: DSM-5 is winning the competition for intermediary information on mental health, which should tell you the public doesn’t merely want information.

Ice-Bitch: of course, but the audience should merely want information and it’s the job of scientists, even Psychiatric scientists, to teach people rationality by confronting them with it and demanding the same from them.

Pangloss: if that was ultimately possible, it would have happened already. We have to make do with a different world in which humans are less perfect and only have a limited capability towards rationality.

Paul Doubtful: I think we are getting close to the heart of the matter here, but before we get dragged into philosophical disputes, it’s time to move to the issue of how DSM-5 will affect the lives of those diagnosed with an illness. As you both know, DSM-5 includes many illnesses that to the lay person might sound a little dubious, like ‘Internet Disorder’, ‘Gender Identity Disorder’, ‘Hoarding’, ‘Binge Eating’, Autism Spectrum’, etc. What do you make of this?

Ice-Bitch: it illustrates my general point that this is the manual for all the losers and money-grabbers in the world. Of course, each brain is unique in that everyone has idiosyncratic mental abilities and limitations. But what purpose is there to call all brain configurations that don’t win a ‘disorder’? The list of exotic limitations that have now been branded a ‘disorder’ are just a list of excuses to lose. I hear that half of the teenagers in the US now apparently have some recognised disorder, often diagnosed at the behest of parents and industry-groups.

Pangloss: again, Ice-Bitch, you say these things as if they are a bad thing. Of course these disorders will be used by people to explain why they are not as ‘normal’ and successful as others in our highly competitive society, but there are surely indeed reasons for why some are more successful than others. Particular mental labels help explain these reasons in a way that leads people to accept their adaptive failure up to that point and thus help them recognise what they have to do in order to be at least somewhat successful. It also creates understanding for them amongst the winners. So, yes, it softens the blow of losing in our society but that is precisely what is so good about the DSM-5: it makes us into a more caring and accepting society. Not everyone can be a winner, fine, but instead of vainly telling those who lose that they should man up and accept they are inferior beings, we give them a place in society. A sense of belonging and where everyone has a 2^nd and 3^rd chance. After all, everyone is a loser in some domain.

Paul Doubtful: If I may interject here, before we get further into this, does either of you know whether mental health disorders are really on the rise and why that is?

Pangloss: probably on the rise, yes, best witnessed by the increase in obesity that is best viewed as a mental health issue. We dont really know about the causes, probably something to do with increases in stress and changed prices.

Ice-Bitch: I agree the rise is partially real and that it is exceptionally hard to find the socio-economic mechanisms behind it. It seems very likely to me though that a lot of that increase is precisely because of the molly-codling that is now taking place which makes individuals, parents, and whole communities less responsible when it comes to teaching individuals good mental habits: the mentally unhealthy get rewarded and taken care of by ‘society’ now, increasing that dependency. I partially blame the previous DSM’s for this. A lot of this must also be just increased measurement of what was already there though. I thus think you underestimate, Pangloss, how much this agenda is pushed by industry interests, a point made by one of the authors of DSM-4, Alan Frances, who is highly critical of DSM-5. Think of the amount of money and jobs involved here: psychiatrists looking for patients to treat, school administrators looking for clients to hen over, government bureaucracies looking for constituents to soothe and please. All these people will ultimately want to get paid by the taxes on the rest of society in order to ‘help’ the mentally disordered, and thus have an interest in finding as many of them as they can.

Pangloss: of course there is a large element of rent-seeking and opportunistic labelling here, but that is normal. Anyone who is trying to sell public goods, whether it is the military or the beach cleaners, will exaggerate the benefits and push politicians for subsidies. That is normal. Rather than see the resources involved as a negative, you should see this as the other great benefit of DSM-5 though: it will lead to a huge number of jobs amongst diagnosticians and mental health carers, people with skills that are probably not all that useful in many other areas. Particularly given the ever reduced numbers of workers in manufacturing, agriculture, and even, down-the-line, education and finance, mental health will be the next great motor of soft-job-creation. And one moreover that is not just based on tax-receipts but has export-potential. There are, as you call them, ‘losers’ in other countries too that want to be taken care of and they often have rich parents willing to send them abroad for help. And, to return to the point about the mental health decline being due to having become more caring, whilst this might well be the case, you don’t see a decrease in the two statistics that really count at the end of the day from a utilitarian perspective: life-expectancy and average happiness. So in that sense we shouldn’t be too concerned about the increase in mental health disorders.

Ice-Bitch: I am not so sure about that one, for stressed individuals are less happy so I am expecting those happiness numbers to go down, but we shall await new data on that one. On the immediate issue of the merits of having a mental health industry, though I can see how there might even be an export industry-element to this, I suspect you will find that the mentally disordered in particular are going to be unpopular immigrants and hence that you will be talking about a small market for particularly well-financed losers. But the basic idea that we should be happy to create jobs without a real benefit to our society is just old-style socialism. Mental health workers cannot just be employed doing work whose benefit really only exists because you first create the problem by telling every loser they have a mental health issue. Down the line, that whole industry is then a pure drag on the rest of society and the more dynamic parts of society won’t stand for it. It is they who will leave, forcing a collapse in the nanny-state left behind, just as we saw in Eastern Europe.

Pangloss: I don’t expect that to happen at all, for four quite distinct reasons. One, I think you will find that even many of the winners would prefer to live in a more caring society and hence will be happy to go along with subsidising the rest. There will of course be a point at which the tax burden might become too great, but international migration markets will tell us where that point is, so there is no real need to worry about that now. Secondly, you should not underestimate the cost of the alternative, which is to have a large part of society angry at being branded ‘simply inferior’ and nevertheless forced to keep competing against the rest. It creates a ‘do or die’ culture in which you have a lot more violence, stealing, cheating, anguish, and disruption. Keeping a lid on the social costs of having a competitive society by giving the rest a mental ‘out’ is thus even indirectly a useful goal for mental health practitioners and saves us tax dollars in other ways, like cops and prisons. Thirdly, I would still maintain that there is a real utility benefit of helping the mentally disordered be diagnosed and treated. It will truly help many of them be more productive and happier. Fourthly, I see no reason why we can’t have a viable industry whose jobs are circular and thus supply-driven. The same principle worked fine in law and I hope you will agree with me that mental health workers are probably going to give more net benefit than tax-lawyers.

Ice-Bitch: on the first point I think you under-estimate how locked-in governments can become and hence how bad things can become before the natural correction takes place. The second point is quite crucial, more so than the third one. The supposed disruption created by frustrated losers is frequently over-stated in that you have had many societies with very little sympathy for losers doing extremely well as societies. Indeed, in many cases we are talking about societies at the height of their strength precisely when they were somewhat brutal in their attitudes to the losers. In the height of the Roman Empire, the winning men killed the losing men and took over the wives of the losers. In the height of Victorian Britain, the losers were sent to Australia. In China today, you see quite brutal competition, together with sustained growth rates the world has never before seen. Yes, they have higher rates of capital punishment than everywhere else, reflecting the pressures in that society, but this pressure is clearly in ‘net’ terms making that society more dynamic and successful, not less. The third point really is just the second point in disguise and boils down to the same false empirical prediction, which is that societies that give losers an ‘out’ would gain in net terms. You see that conceit a lot in the literature on mental health, whereby it is frequently claimed that huge numbers of working hours would be gained if we’d make the mentally unhealthy more mentally healthy. Precisely because the world of work is the world of winning though, such claims are wrong. It is rather like saying that one could have 4 times more gold Olympic medals if the losers would have run a bit harder: true on the margin but complete nonsense for the system as a whole because the number of winning slots is by design somewhat fixed. I suggest history thus shows the opposite of the idea that it makes sense to soothe the losers. This is part of the point of treating people as rational and responsible adults: yes, it creates a lot of angst, but it also makes a lot of people more resilient and determined. It educates them to be more rational and successful. In the long run, ‘tough love’ is evolutionary successful and thus ‘real love’.

Pangloss: we read history differently. Whilst I am not disagreeing with you on the merits of brutal competition to the dynamism of society-as-a-whole, I think that you are cherry-picking the competitive societies that were successful and neglecting a large element of cooperation in those societies, alongside the brutal competition. Also though, we are no longer in an age in which the world can afford the single-mindedness that accompanied those earlier Empires. Don’t forget that the Romans, the Victorians, and many such other Empires, were also conquering countries with tremendous degrees of national pride and self-belief that made them quick to get angry at their neighbours. Precisely because the internal competition was so brutal did those countries also behave ruthlessly in the international arena, taking tremendous liberties with international peace and cooperation. In an age of all-destructive weapons held by all big countries, the world simply cannot sustain that level of aggression. Hence I am very happy to see that even in China, which indeed has brutal internal competition, there is a strong move towards the restoration of a welfare state, including universal health care and education. It may take another generation, but they are going to be just as sedate as we are and that is a good thing. So even though in principle I agree with you that treating people as responsible rational adults makes them more responsible and rational on average, I think the age in which that normative approach to rationality, where it was the Enlightenment ideal to be a rational responsible person, is simply no longer the optimal model for societies today. We don’t want countries that are that dynamic and it is not optimal for an individual country to be that dynamic because it leads them into war too often. Within our countries, the truly talented will still be quite rational because that benefits them personally as they can win, but I see no problem in letting the less talented be less pushed to be rational. Even in the past, they were not really all that rational anyway, with beliefs in unseen deities and magic taking the harder edges off their competitive societies. DSM-5 in that sense is thus, at worst, going to lead to contented hidden unemployment, ie to ‘losers with dignity’ and health carers who have a ‘welfarist job with dignity’. A sedate society, yes, but one that is a good world citizen.

Ice-Bitch: I think that is where we then differ most. I want my society to be the more dynamic one, to push the boundaries and to keep history interesting, even if that is internationally perilous. DSM-5 belongs to a world that becomes dull, predictable, and leaves much less room for the talented and strong to enjoy their lives and make the most of it. It seems you are the more pessimistic one in that your world will not find a way to cope with more dynamic countries. Don’t be so pessimistic, Pangloss!

Pangloss: a Paradise Lost, I think. Get over it, Ice-Bitch. Chill out, you seem like you will do well enough under DSM-5. I am sure there’s a disorder in there with your name on it.

Paul Doubtful: and that’s all we have time for today. I found it very enlightening and refer the interested listeners to some of the previous, less crystallised, discussions on this topic by these two thinkers (here, here, here, and here). There are clear overlaps here between the discussion today and the literature on resilience. You might want to check out the recent book by Gilles Saint-Paul on similar themes (‘The tyranny of Utility’).

Don’t forget to vote, and thank you to our panelists who I am sure will keep disagreeing with each other!

Ice-Bitch\Pangloss: thank you.”