Cause or Effect – Evolving Definitions

Are mental disorders harmful by definition,
OR are they simply
conditions that quite often cause problems?

Should someone who has “symptoms,”  but suffers NO harm, be diagnosed with a mental disorder?  With each edition of the DSM, the link between harm and disorder has shifted.  The requirement that disorders cause harm, was recently dropped from the definition of mental disorder.  DSM-5 allows for far more people to receive a diagnosis than previous editions.  While this may be of value to those who could benefit from workplace accommodations, it raises an important question…

Why must an employee be required to reveal a label in order to persuade his/her employer to provide “reasonable” accommodations; especially those (such as flexible hours, or working from home), which could potentially increase productivity for many employees…whether or not they have a “label?”  If the accommodation is “reasonable,” wouldn’t it be wise for any reputable employer to honor such employee requests? Why are so few employers willing to trust employees intentions?  Especially those, who are self-aware, motivated, and well aware of which tools have proven to maximize their potential in alternate situations?

Disorder or Difference

Must Disorders Cause Harm? The Changing Stance of the DSM – In her book, The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel, Rachel Cooper explores the issue…Should someone who has “symptoms,”  but suffers NO harm, be diagnosed with a mental disorder, or should they just be considered “different?”  Cooper suggests, If mental disorder by definition causes harm, then a flourishing individual cannot be diagnosed. They are simply different. In contrast, if mental disorder is merely “typically associated” with harm, then the happy person with Asperger’s can be given a diagnosis.”

These crucial questions have not been given the attention they deserve. The idea that disorders are linked to “distress or impairment” was introduced in the DSM-III, following the removal of homosexuality from the DSM in 1973, which is why sexual orientation is no longer considered a “mental illness.”  In the DSM-IV the general definition of mental disorder and many of the individual diagnostic criteria sets continued to require that symptoms cause (or at least increase the risk of) distress or impairment before a disorder could be diagnosed. Most recently, however, the requirement that disorders cause harm, or an increased risk of harm, was dropped from the definition of mental disorder with the publication of DSM-5. This means that individuals who have “symptoms” of mental disorder, but do NOT suffer distress or impairment (or are at an increased risk of suffering distress or impairment in the future) can now be diagnosed.

Now that the definition no longer requires harm or distress in order to diagnose “atypical” behavior as a “mental disorder,” the question is again being raised as to whether homosexuality should be reinstated within the DSM.  If not, why must individuals with ADHD, Autism, and Learning Differences be considered to have a “disorder,” especially when they do not experience harm or distress?

Evidence of Brain Differences

Twin and adoption studies have demonstrated that sexual preference has a genetic component.  According to Scientific American, “Genes can’t control behavior completely, though. Genes regulate the production of amino acids, which combine to form proteins. The existence or absence of a protein can have an effect on things like alcohol tolerance or mood.” But like alcoholism and depression, the predisposition may be impacted by environment, culture, and temperament. Other studies have indicated that in fact, the structure of the brain might influence sexual preference. Whether it be differences in the hypothalamus, which controls the release of sex hormones from the pituitary gland; the symmetry of the brain; connections in the amygdala (which receives sex hormones); or exposure to sex hormones in the womb during a critical period in brain development (as demonstrated in rats), the research is inconclusive.  However, the same could be said regarding the research on brain differences pertaining to those whose “behavior” and/or subjective experience, has led them to receive a diagnosis of autism, ADHD, anxiety, or bipolar disorder.

Inconsistent Arguments 

The media cites that for decades practitioners of conversion therapy have falsely claimed that homosexuality is an illness, or a behavior, or a choice, and gay people, often through religious-based “therapy,” could be cured of it, to become “normal.”  This concern gave way to anti-conversion campaigns stating the opposite, and on May 19, 2015 Democratic U.S. Congressman Ted Lieu of California, introduced his proposal for the Therapeutic Fraud Prevention Act. If passed, the law would classify conversion therapy as a fraudulent practice that would be illegal under the Federal Trade Commission Act. The law would also ban all advertising that claims the therapy can successfully change a person’s sexual orientation or gender identity. Lieu expressed that “what this bill seeks to do is to reaffirm what medical science has already stated formally: Being gay or lesbian or transgender is not a mental disease, illness, or defect that needs any sort of cure.”

IF the science behind gender and sexual orientation reaffirms that variations in sexual orientation or gender identity are NOT “mental diseases, illnesses, or defects that need any sort of cure,” why doesn’t that same research apply to those with other brain differences…And WHY should individuals and “mental diseases” be cured, and why are these “differences” considered diseases, illnesses, or defects?

We can probably all agree; labeling the majority of mental differences, as “illness” to be “fixed,” does more harm than good. The reality is that in most cases, it is the genetic differences, which affect the functioning of the brain (the organ responsible for behavior), and the ways in which the brain processes information.

Labels – Accuracy and Intention

Is Homosexuality A Mental Disorder?  All major professional mental health organizations have gone on record to affirm that homosexuality is NOT a mental disorder. In 1973 the American Psychiatric Association’s Board of Trustees removed homosexuality from its official diagnostic manual, The Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM II). The action was taken following a review of the scientific literature and consultation with experts in the field. The experts found that homosexuality does not meet the criteria to be considered a mental illness. The APA’s nomenclature task force recommended that homosexuality be declared “normal.”

However, in Homosexuality: The Mental Illness That Went Away, Phil Hickey suggests,

Real illnesses are not banished by voting or by fiat, but by valid science and hard work. There are no mental illnesses. Rather, there are people. We have problems; we have orientations; we have habits; we have perspectives. Sometimes we do well, other times we make a mess of things. We are complicated. Our feelings fluctuate with our circumstances, from the depths of despondency to the pinnacles of bliss. And perhaps, most of all, we are individuals. DSM’s facile and self-serving attempt to medicalize human problems is an institutionalized insult to human dignity. The homosexual community has managed to liberate themselves from psychiatric oppression. But there are millions of people worldwide who are still being damaged, stigmatized, and disempowered by this pernicious system to this day.

Vivek Datta, M.D., M.P.H. addresses the fact that all diagnosis making is a sociopolitical act.  Both the inclusion, and expunging of homosexuality from the DSM were sociopolitical in nature.  In his insightful commentary in Mad In America, entitled, When Homosexuality Came Out (of the DSM), he acknowledges that

The pathologization of homosexuality convinced some individuals that they were sick, and that in itself may have made them (feel) sick! The removal of homosexuality from the psychiatric canon has undoubtedly facilitated the rights of those who identify as lesbian, gay, or bisexual. Adoption rights, same-sex marriage, the repeal of Don’t Ask Don’t Tell, would never have occurred if homosexuality continued to be seen as the developmental end-point of deep psychopathology. In the same way, diagnoses of mental illness, confer individuals with a sense of otherness, that they are somehow different than other people, perhaps less important, less deserving, or of less worth.

These diagnoses confer social meaning not just for those labeled so, but also come to signify what it means to be without disease or disorder. Taking the example of homosexuality, its appearance as a social and medical concept at the end of the 19th century, also coincided with the invention of heterosexuality. Psychiatry was thus instrumental in creating and polarizing sexual identities in a way that persists today despite the demedicalization of sexual orientation. Diagnoses thus convey not only information about the treatability and prognosis of particular states, they also create identities, confer recognition, or conversely erode personhood, and our ability to construct meaningful narratives beyond the medico-psychological discourse.

Viewpoints regarding mental illness vary from country to country, and practitioner to practitioner.  Some perceive the DSM as a book of laws, or moral codes, based on standards of behavior.  If you violate these laws, you are labeled as mentally ill.  And, as society’s morals change…so does the definition of mental illness.  Are the changes based on science, opinions related to religion, or the progress of civil rights, resulting in the understanding and acceptance that differences need not be considered disorders?  These very important and interesting questions are posed within a (somewhat anonymous) presentation, entitled, Gay Sex A Mental Disorder? ADHD, Psychiatry, Psychology, Mind Control.

Be Counted!  Illuminate Mental Diversity at Work.
There is safety (AND strength) in numbers. “All for one, and one for all.”

Suggestions, feedback, comments, and questions welcomed at MindingDiversity@aol.com

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© October 2015

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