Whistle While You Work, Stevenson’s a Jerk

September 22, 2016

When was the last time in the midst of a presidential campaign that psychiatric diagnostic criteria were being discussed so widely?

I guess I’m supposed to be happy-but I’m not. After all, when was the last time in the midst of a presidential campaign that psychiatric diagnostic criteria were being discussed so widely by leading politicians and the media? The first time I can remember (and that wasn’t nearly such a broad and ongoing discussion) was when it was revealed during the 1972 presidential campaign that the vice presidential candidate, Thomas Eagleton, had been treated for depression with ECT. The very popular senator from Missouri and George McGovern’s senate colleague and hand-picked running mate was promptly dumped by McGovern in spite of no evidence that Eagleton was impaired. It is no small irony that McGovern much later revealed his long-standing troubles with alcohol addiction and mood troubles.

So why am I not thrilled that the largest number of people ever in the history of our country are being regularly exposed to the diagnostic criteria for several personality disorders, bipolar disorder, and likely several others before November comes around? This is far more free publicity about psychiatric diagnoses than happened when the American Cancer Society likely spent a small fortune to publicize what they called “the 9 warning signs of cancer” or when the American Heart Association publicized signs of a heart attack. The American Psychiatric Association’s sales of DSM-5 must be skyrocketing.

I’m not happy about all this free publicity because of the reason for it and because of the nature of it. The US, as does most every country, has a long history of using personal qualities and personality traits to criticize candidates for office. And to some extent those are valid parameters to consider. But having politicians, newspaper columnists, and television doctors (“I’m not a psychiatrist, but I play one on TV” types) throw around diagnostic criteria and diagnoses as if they actually know what they are talking about is more than just depressing. It’s demeaning both to those who are actually trained clinicians and, more importantly, to patients afflicted with a real psychiatric disorder.

I actually heard one purported television clinical expert say that one of the candidates couldn’t have one of the frequently used personality diagnostic descriptions because if that were true, the effects would definitely be visible to us in any offspring. And, because there was no such evidence from a younger generation member that has been visible, then the original diagnosis couldn’t be true. Does this “expert” actually think we know anything about who these people really are-especially the non-candidate family members? Does this person think the public performances during campaigns, either formal or informal, are anything other than well-scripted playacting, even perhaps in a candidate who might be critiqued for going off the script? Could anyone who is selling his or her expertise on TV actually be that naive?

All this must certainly, though, make for great television ratings.

There’s a good reason that the ethical standards for American Psychiatric Association members say no one should make a diagnosis about a public figure without having personally evaluated that person in a clinical setting, and certainly not discuss it publicly without that person’s permission. I won’t belabor the point about the art of clinical diagnostic decision-making, especially when it comes to personality disorder diagnoses. But every experienced clinician knows it’s much more than simply checking off the diagnostic criteria in the DSM or ICD checklists. And doing any kind of diagnosis based on snippets of information from TV performances should be too ridiculous for any serious person to consider.

What is really going on, to me, is that the use of a psychiatric diagnosis to impugn the person who purportedly has the diagnosis is to stigmatize everyone else who may have it. Psychiatric disorders are being used as sledgehammers against candidates-and no side is exempt, since “having a screw loose” or “having their brain fried” is just the vernacular to delegitimize someone without the patina of professionalism.

Every fourth-grader has already learned how to denigrate a playmate, classmate, or relative by calling them personally derogatory names. I can imagine the next generation of 10-year-olds saying “your dad’s just a sociopathic, narcissistic, hypomanic jerk” instead of “so’s your old man.” (I must admit I think the latter phrase has a better ring to it.) Likely that’s just a generational thing, and some 10-year-old will say it’s just because I’m an old fogy (or the modern, much more profane equivalent). Luckily for our society, most of us more or less outgrow our 10-year-old selves, not to say that remnants don’t remain. Freud did know what he was talking about when he described regression as a response to stress.

Most everyone who has ever worked in stressful emergency or impatient psychiatric settings knows how tempting it is, but how destructive, to label difficult and uncooperative patients as “borderline.” One of my long-standing teaching emphases with medical students and beginning residents is to use self-reflection, discretion, and thoughtfulness before labeling specific behaviors as indicating a particular diagnosis. Some patients in these clinical settings do have borderline personality disorder-but no particular behavior reflects a specific diagnosis as we well know. Unfortunately, labeling a patient borderline can often mean only that they are disruptive, angry, and difficult to deal with. Using that label can be a way of dismissing the patient. A parallel process seems to be going on in the presidential campaign.

Unfortunately, personal denigration has always been an integral part of politics around the world. And people do it because they think it works. And maybe, to some extent, it does. After all, if I could have voted as a 9-year-old in the presidential election in 1956, I would have voted for Eisenhower because all I knew about either candidate was this ditty that was very popular in my elementary school (to the tune of “Whistle While You Work” from the Disney Snow White cartoon film):

Whistle while you work Stevenson’s a jerk Eisenhower has all the power Stevenson’s a jerk

I would like to see every mental health association make public statements about the terrible disservice to all patients with psychiatric illnesses that is occurring by the stigmatizing use of psychiatric diagnoses in our presidential campaign. This is a good opportunity for some real public education about psychiatric diagnosis and illnesses. Though I doubt it will have too much effect on the presidential campaigns or the media, we would certainly be on record about the destructiveness and harm of the current use of psychiatric diagnoses to stigmatize candidates in the present campaign.

I hope by the time you read this that many people will have spoken out.