Psychiatric Times.

Vice Squad

By John Z. Sadler, MD | August 26, 2010

Are psychiatrists agents of the police or doctors who care for the sick? Thomas Szasz raised this question 50 years ago in his iconic “The Myth of Mental Illness.”¹ Psychiatry has changed in the ensuing decades, but Szasz’ question is still relevant. Why?

Consider the diagnostic criteria for Conduct Disorder in DSM-IV-TR: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=370#

The DSM-IV criteria are currently not to be modified in DSM-5, according to the 8/4/10 version of the DSM-5 website. Look at the diagnostic criteria. Every one of them specifies a behavior that is either criminal or morally wrongful - the subcategories of the A criteria say it all: “Aggression to people and animals,“ Destruction of property,” Deceitfulness or theft,” “Serious violations of rules.”

Consider other DSM-IV-TR categories like Antisocial Personality Disorder: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=16#

Every one of the A-section criteria are wrongful acts, and indeed read like a list of vices: deceitfulness, aggressiveness, reckless disregard, irresponsibility, etc.

How about the paraphilias that involve “nonconsenting others” - conditions like Pedophilia: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=186#

...or the DSM-5 proposed Paraphilic Coercive Disorder: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=416

Both of these categories describe little more than what, in the lay view, are immoral thoughts and criminal acts.

In contrast, examine the diagnostic criteria for classic mental disorders like Schizophrenia and Bipolar Disorder, and you will find little in the way of what I call “vice-laden” diagnostic criteria—that is, criteria that describe immoral or criminal conduct.²

In my view, building diagnostic concepts around vice (wrongful/criminal conduct) is a problem for psychiatry and for the public sphere. For the problem of stigma, vice-laden diagnoses perpetuate the public perception that psychiatrists are social control agents and that we serve as morality police, not physicians with a humane charge of caring for the ill. As a second problem, vice-laden categories lead to weird categories of psychopathology. Why are we classifying some sex offenders as ill, but not others? Why are some serial rapists (eg, Paraphilic Coercive Disorder in DSM-5) considered ill, while serial murderers, including paraphilic ones (see Krafft-Ebing’s “Lustmord” cases³), do not warrant their own diagnostic category? For a more socially provocative angle, why are petty criminals diagnosed with Antisocial Personality Disorder and no“Insider Stock Market Trader Disorder” is proposed as a diagnostic category? The commingling of vice in our diagnostic categories mixes crime with mental disorder, and we can all recognize the mess encountered with mentally ill offenders: Where do they go? What system(s) should care for them? Do we rehabilitate, treat, seclude, or punish? Does the insanity defense apply to this or that diagnosis?

Our handling of vice—wrongful and/or criminal conduct—in our diagnostic thinking appears arbitrary and is irrational, inconsistent, and misleading. While likely rooted in our history, clinical traditions, and the Zeitgeist, its handling in the past and future DSMs leaves much room for better concepts and better science. In later blog entries, I’ll sketch some ideas about how this could be done, and wrap the problem of vice-laden categories into the context of other conceptual problems in the DSMs.

References
1. Szasz TS. The myth of mental illness. Am Psychol. 1960;15:113-118.
2. Sadler JZ. . Vice and the diagnostic classification of mental disorders: A philosophical case conference. Philos Psychiatr Psychol. 2008;15:1-17.
3. Krafft-Ebing R. Psychopathia Sexualis: A Medico-Forensic Study, translated by Wedeck HE. New York: G. P. Putnam’s Sons; 1965.

by Stephen Mack | August 29, 2010 6:08 PM EDT

Suggest you rent the DVD of Fritz Lang's brilliant and bracing "M" and discuss amongst yourselves how you as physicians would deal with Hans Beckert.

by Andrew Hinderliter | August 29, 2010 1:12 PM EDT

In my Defining Paraphilia: Excluding Exclusion, I look at arguments for including the"paraphilias"in the DSM and find that the arguments given for including it in DSM-III (by DSM-III architects) were inconsistent with other arguments by the same people and with how DSM-III actually defined (at least some of) the paraphilias. Furthermore, those arguments wouldn't justify including them in DSM-III-R given changes that were made there (which made them even closer to the simple medicalization of crime.) From the arguments I review, I have a strong suspicion that the main reason for keeping these in the DSM is fear of negative public reaction to removing them.

In discussions of vice-laden mental disorder classifications, an important (though not overly philosophical) question that I think is utter essential is, "If some of these were removed from the DSM, how could the APA spin it so as to avoid intense negative public reaction?"

by Ronald Pies | August 27, 2010 4:47 PM EDT

I appreciate Dr. Sadler's thoughtful remarks and concerns, and I agree that some of our "vice-based"diagnostic categories are deeply problematic. One way of guarding against inclusion of such "bad behavior" categories in our nosology is to begin with a foundational definition of "disease". As I have suggested in several papers, the core features most critical to such a definition are intrinsic suffering and substantial incapacity.

Many, if not most, so-called pedophiles and antisocial individuals lack one, or both, of these features--these individuals are more often the cause of suffering and incapacity in others than people who experience these themselves! (One can't generalize too broadly, of course; there are some in both categories who do indeed experience "suffering" as a result of their psychological make-up).
I'm aware that some would argue (as my teacher and colleague, Tom Szasz often does) that all psychiatric diagnoses are merely reified collections of behaviors that we don't like, or which society deplores. But anyone who has treated patients with schizophrenia or severe melancholic major depression knows that, on the contrary, these individuals would very likely experience suffering and incapacity even on the "desert island" that I describe in
some of my postings on this website [see, "What Should Count as a Mental Disorder?"]

Best regards, Ron Pies MD

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