In Praise of Disorder

Unless you live in a cave in Patagonia, you will have heard angry mutterings about whether people, especially young people, who have decided they were born the wrong sex/gender, should be given medical assistance/treatment while they "transition" to the opposite gender/sex when they ask for it. In Britain, a years-long review of gender identity services for young people has just been published [1]. At 388 pages, it's well down my "must read" list, especially as it's unlikely to settle the endless arguments, but there's an interesting graph on p85 showing how, over the past 10yrs or so, the number of cases has exploded. From perhaps 150 cases a year in 2010-11, NHS clinics are now seeing about 5000 cases a year, of whom the great majority are "birth-registered females" aged 15 and 16. For an alleged brain condition, that's a very peculiar distribution. A graph on the next page shows that from 2009-21, the incidence of what is now called gender dysphoria increased over 100 times. Again, does not lend itself to a simple explanation.

We're also getting alarms about another hot topic, internet addiction. A drug-company freeby called Addiction Medicine Research Review opens with three articles on the topic. First one, from China, found strong correlations between "smartphone addiction" and social isolation/loneliness, and general misery. Students with good family connections were happier, more social and spent less time on their phones, which is hardly surprising. The next paper found "The prevalence of moderate-to-severe internet addiction among young adults in Malaysia is almost 30% ... Internet addiction leads to poor dietary habits and a higher preference for energy-dense convenience foods." The final paper came from Qatar, which is extremely wealthy, has near-universal internet usage and lots of bored citizens as they have swarms of servants and labourers from Asia to do everything for them. They found that adolescents who were addicted to the internet also complained of physical and mental fatigue.

In last week's post on the surge of people either demanding or getting a diagnosis of "autism," I pointed out that there is no reliable means of distinguishing between their favoured diagnosis and personality disorder. Part of the trouble came from the very flexible "diagnostic criteria" for autism, in that completely opposite behaviour can still get the diagnosis. For example, a person can be highly organised and fixed in ordered routines, or totally disorganised, and still qualify. As the presenter said, a very rigid and inflexible person and a chaotic person are "often two sides of the same (autistic) coin." He added: "One of the reasons I need routine and stability and security is because I'm so flexible." Similarly, high sensitivity to external stimulation (light, colour, noise, smells, bustle etc) and low sensitivity are typical features of autism. Another person can be very social, or not social at all; somebody can be overwhelmed by other people's emotions or not detect them at all; one person can be withdrawn all the time while another has "ups and downs, very social and energetic or not wanting to mix at all." That is, two people can show entirely different sets of symptoms and signs, with no overlap at all, and still get the diagnosis.

There was no suggestion as to how anybody could separate autism from personality disorder, or even an inkling that there may be an issue. The end result is exactly what we see: droves of people either labelling themselves or being given the label, not with the goal of changing their behaviour but to cement it in place (and perchance to gain social security benefits along the way). We could mention some other recent secular trends (I use that expression to avoid saying 'epidemics,' which they're not, and 'fads', which they are but psychiatrists don't like). The first is the endlessly-expanding ranks of people with ADHD. As usual, the US leads the way:

In 2019, nearly 10% of United States (U.S.) children had a diagnosis of ADHD. Approximately 3.3 million children, or roughly 5 out of every 100 children in the U.S., are currently prescribed medication for ADHD (i.e. late 2022).

As Martin Whitely has documented over many years, Australia is following close behind [2; also see his website for updates]. The second "epidemic" is so-called bipolar disorder. Bob Whitaker has analysed the figures showing the trend [3]; the mechanism of the trend is that psychiatrists are encouraged/pressured to diagnose bipolar disorder and prescribe drugs because not making the diagnosis is a much worse error than a wrong diagnosis [4]. So where do "epidemics" end? Badly, as the opioid crisis in the US shows: half a million or more unnecessary deaths, just because a couple of drug companies saw the chance of making enormous profits. If a car company's product had caused half a million deaths, there would have been an uproar but drugs? Who cares?

These trends are part of the broader medicalisation of society, the slow but relentless manipulation of our way of thinking [5], away from the humanist principle of seeing people as individuals with free will, to seeing humans as biological puppets dangling from threads of DNA. We are steadily getting rid of the idea that people can be different, eliminating eccentricity or amusing quirkiness and replacing them with illness. The basic principle that all people are different, and are allowed to be different, is disappearing, replaced by the urgent need to conform.

In the old days, psychiatrists accepted that personality disorder wasn't really their problem because they had no treatment for it. By definition, mental illness requires drugs; personality disorder isn't an illness; therefore no drugs for them. If the patients were pests and kept coming back, they could see the psychologist; if they were rich, they could see a private psychiatrist but apart from that, the rule was Don't bother us, we're busy people. And that was fine, it meant that orthodox psychiatry kept within its narrow limits and generally kept a low public profile. Of course, it meant that lots of people in distress didn't get anything beyond a few valium but it stopped psychiatry getting imperial pretensions. Until DSM-III, in 1980, that is, then it all changed. The biological people took control of psychiatry, expelled all the silly (and mostly old) people who believed in minds and all that mumbo-jumbo, and proclaimed their Brave New Biological World. Echoing the positivist credo but mostly not knowing anything about it, they dumped all talk of minds, personality and all that airy-fairy stuff and got stuck into the brain enzymes.

And with the talk of personality went, naturally enough, all talk of personality disorder. Suddenly, psychiatrists who had confidently called patients "manipulative" or "aggressive" or "suspicious" or "neurotic" or "rigid" or "attention-seeking" had to come up with a new language. At about the same time, the PC trend was surging, it was no longer good enough to throw such terms around as they were seen as moral judgements. People weren't aggressive, they were misunderstood; they weren't attention-seeking, they were affection-deprived; and so on. This was code, of course, we all knew what it meant underneath, but psychiatry had an unassailable fall-back position: troublesome people were reclassified as "mentally-disordered," given a bright new diagnosis and some lovely tablets and sent on their way. That way, staff could say what they liked and nobody complained as the label reflected on the patients' newly-acquired brain disorders, not on their morality.

But that's all history now, what counts is that if it is legitimate to talk of "normal personality," then it's also legitimate to talk of "personality disorder." Is there an value-free science of personality? Yes, there most certainly is. Not a good one, I'd be the first to say, but it exists and can be discussed objectively. As for personality disorder, psychiatry has twisted itself in knots. Profitable knots, for sure, but still knots. Thus, the latest DSM (No. 5) has a section on personality disorder, but it's right at the end, the eighteenth chapter out of nineteen, which tells you their priority. To make it worse, there is, of course, no definition of personality and therefore none of personality disorder, only descriptions. That’s because none of the Key Opinion Leaders who wrote DSM5 know what personality is, therefore none of them can talk of the unobservable mental mechanisms that produce the distress and/or disruption of personality disorder. Rather than admit their ignorance, they are happily engaged in the very profitable process of labeling nearly half the population as "mentally ill," and hang the consequences. And so the medicalisation of society proceeds apace. 10% of children in the US have a diagnosis of ADHD. 20% of adults in the UK take antidepressants and the UK suicide rate is going up, not down. Wow, why don't we put antidepressants in the water supply?

In the YouTube videos I watched to pen last week's enlightening column, the presenter asked: "How do you know you're autistic? Nine Common Ways to discover your autism as an adult." No. 5 was: "A long time search. You've always had this niggling question in the back of your mind, you get a diagnosis that doesn't quite fit." In another video, he asked: "Are you autistic? 25 questions to ask yourself." The last was: "Have you been diagnosed with depression or anxiety or other labels that either keep changing or don't quite fit?" If so, that's autism. But let's not be too impulsive: it could also mean the diagnosis of a mental disorder was wrong, and the correct assessment is, not autism but personality disorder. This is highly likely as the diagnostic criteria of autism, or bipolar type II, or adult ADHD, or gender dysphoria, or internet addiction, and all the rest are indistinguishable from the criteria of personality problems. There's no cut off point, no way of saying "This is where personality disorder stops and autism starts."

Normal personality merges imperceptibly with abnormal personality. Normal personality is a huge range, not a unique category, but if, like mainstream psychiatry, you don't have a theory of personality, you can't say that. In a rational system, the model of personality disorder derives directly from the theory of personality which, I argue [6], is a subset of the theory of mind, which mainstream psychiatry also doesn't have. So in the absence of these fundamental features of a scientific field, anything goes. That's why huge numbers of teenage girls in the UK are suddenly deciding they should have been boys: "Look at me, I'm a misfit, a disaster as a girl. Aha, that means I'm really a boy, hand me the testosterone and that will fix the problem." It doesn't, of course, as they're finding out (see [1]).

Let's summarise this:

1. Personality is a real thing. The positivist drive to eliminate all unobservables from the human sciences, including personality, was a dreadful mistake, an epistemological injunction hiding a moral imperative.

2. Personality disorder is a real thing. We have very good evidence of how it arises. The factors that produce it are very widespread and deep-seated in societies. Personality disorder is therefore common while true transsexuality is very uncommon. Remember that common things occur commonly, and uncommon presentations of common things are more common that common presentations of uncommon things.

3. Personality disorder is not a mental "illness" in any sense of the word. Physical treatments of (supposed) mental illnesses cannot and do not work on personality disorder.

4. Psychiatrists have nothing sensible to say about personality disorder. It is now widely seen as a moral judgement.

5. By loosening the diagnostic criteria, psychiatry is steadily encroaching on the field of personality disorder, reclassifying it as various "genetic mental illnesses."

6. The new diagnoses people get are essentially a random matter, either something they have chosen themselves based on social media algorithms, or at the whim of the psychiatrists who can rearrange the symptoms to suit any number of diagnoses according to their fancy.

7. This process will get worse before it gets better. If the history of psychiatry is any indication, it will end badly. Bad for society but worse for the individuals who trust the professionals to do their job properly.

The idea that saying anything about personality disorder must be a moral judgement comes from positivism. If personality is unobservable, we cannot say anything objective about personality, so anything we say must be subjective, i.e. moral. That's where the problem lies, and it means that huge numbers of people are put on drugs they shouldn't have, and deprived of the "talking cure" which they should. I never had any trouble telling people their problems were personality-based and they didn't need drugs. Mostly, they were very relieved although occasionally, they stamped off (or were dragged off by an angry parent) to see a more enlightened shrink who would give them the label they felt they needed.

The point is that we need to get away from seeing a diagnosis of personality disorder as demeaning. Everybody has a personality, and the chances of scoring dead normal on all personality factors are close to zero. For myself, who would want to be normal? What a horrible thought, it's the sort of thing you could scare children with: "Can you just stop being so damned normal? You want to end up in the public service like your uncle Bill? Well, you'd better lower your game, junior, or that's what's waiting for you."

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References:

1. Independent review of gender identity services for children and young people: Final report. (Cass Report). April, 2024. https://cass.independent-review.uk/home/publications/final-report/

2. Whitely M (2021) Over-Prescribing Madness. What's driving Australia's mental health epidemic? Melbourne: Wilkinson Publishing.

3. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.

4. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

5. Roberts, A. (2023). The biopsychosocial model: Its use and abuse. Medicine, Health Care and Philosophy. https://doi.org/10.1007/s11019-023-10150-2. ePublication April 17th, 2023.

6. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge.

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