What a dichotomy! Society is grossly misinformed as well as uninformed about mental illness, yet doctors can over-diagnose the population. There seems to be too many cases of mental illness or disturbance being overlooked or down-played, while on the other hand, there are cases where psychopathology just doesn't belong. For example, the new DSM-V will include an overindulgence of video game playing as a mental disorder! I can understand how something can become a "disabling" factor in one's life due to an overabundance of something. It is certainly the magnitude of a problem that makes it a problem. However, the DSM doesn't allow for criteria to be distinctive enough for psychologists (who may misdiagnose and who have because of a lack of distinctiveness or vagueness) and for the layman as well.

The first parent who cannot get their child to stop playing Mario and Luigi, will probably assume that their child should be seen by a psychologist for "video game playing" pathology. I think we need to be sure that we are setting appropriate limits for psychologists' diagnosising privilages and help society understand that psychology is not trying to pathologize everything.

Although I am a consummate team player in the realm of psychology, I think psychology has created quite a delimma for itself, and perhaps starting with how the DSM classifies mental illness. I'm sure someone can agree that the criteria to meet a particular disorder is often very vague.

If I believed that adding more and more disorders to the DSM meant improvements in treatment or that they actually represented "mental illness", I would be far more sanguine about all of this. But I don't believe it. I believe that money is at the root of this -- greater sales of psychopharmacological drugs, more reimbursable categories and still no solid theoretical underpinning to the whole enterprise. Mental illness has been defined down to behaviors a committee can specify and agree on. Nothing about etiology or treatment. Psychology has become completely ensnared by this atheoretical medical model.

Psychodiagnosis is a way of understanding certain patterns of symptoms and behaviors that patient's (and often those around them) suffer from. The DSM-IV-TR, when properly used, is designed to be atheoretical and phenomenological, i.e., descriptive rather than explanatory. It is my position that any clinician, no matter what his or her theoretical orientation, must be able to properly diagnose as part of being a competent practitioner. I say this while at the same time recognizing the serious limitations, misuses, misinterpretations and economic interests vested in the use of DSM-IV-TR by both the pharmaceutical and insurance companies. For me, psychodiagnosis is the acknowledgment and skilled recognition of archetypal patterns of human suffering so severe as to warrant being seen as "illness," or pathology. These patterns and the suffering they bring are not figments of imagination. They are existential and archetypal realities of the human condition. To "treat" such incapacitating conditions, we must try to know as much about them as possible. The "medical model," from which the practice of dia-gnosis (knowing through) derives, is definitely problematical in certain ways when applied to the practice of psychiatry and psychology. But throwing out the proverbial baby with the bathwater is not the solution to this dilemma. This a situation Jung described as "the tension of opposites." We must be able to hold both paradigms, i.e. the medical or scientific model and the more humanistic or existential approach, in mind when evaluating and "treating" "patients," two more terms from the medical model. I am happy to continue this essentially philosophical though pragmatically important discussion with you, professor Lane, and our readers. But my point in this particular posting was not to debate the pros and cons (which are many) of the medical model and DSM system of diagnosis. It was to say that if we are going to use such a system, which I believe is necessary and useful up to a point, it needs to include diagnostic descriptions that more accurately describe the pathological presentations of anger or rage that have become so pervasive today, and recognize that these are primarily anger disorders, related to the chronic mismanagement of normal or existential anger. I would also mention here Freud's remark that one of the goals of psychoanalysis (psychotherapy) is to transform "neurotic misery into common unhappiness." He was referring here to the fact that life always includes some suffering, but that as psychotherapists we must differentiate between "normal" or existential suffering and suffering which is pathological and debilitating. Psychodiagnosis is one of the ways we have of doing so. But to properly diagnose someone is not the end of a treatment process, but only the beginning. A person is much more than a diagnosis, and we clinicians must remember that when we reduce a person to a particular diagnosis or symptom-set, we are losing sight of that person him or herself, the person that is experiencing our diagnostic criteria. We haven't even gotten into here the highly questionable presumptions of mainstream psychiatry regarding the causes of so many psychiatric disorders such as schizophrenia, bipolar disorder, ADHD, depression, anxiety disorders, etc. That is for another day.

It seems to me that the behavioral and social problems associated with the effects of the repressed anger are particularly evident--and problematic--in the American society. Is is any wonder that people smolder inside for long years when they are treated like meaningless cogs in the capitalist, profit-making machine? No decent pay, no vacation time, no humane and accessible health care, and in general inhuman treatment in the workplace, growing social inequities, and unstable familial bonds, compromised and fractured by the forces of the for-profit existence forced upon individuals in the morbidly capitalist society, tend to lead to frustration, anger and rage. Unfortunately, instead of directing it at the way their society is structured--and trying to change it, Americans take it out on each other--or on the Other, leading to pointless wars and international conflicts.

The Diagnostics and Statistical Manual (DSM), the Shrink's bible, has been around for over 50 years. Within this manual, there are now possibly nearly 300 mental disorders.

The latest DSM, the DSM IV, was made available in 1994. The next DSM V will have its first draft finished by the end of 2010- and will be published in 2012.

As a thorough dictionary of suspected mental illnesses, many redefined or recognized diagnoses are added to this manual with each edition often.

This is particularly the case if medicinal therapy exists as a treatment option for certain mental illnesses.

On occasion, a mental disorder is deleted from the DSM, such as homosexuality in the early 1970s.

Its purpose, this manual, is to assist mental health professionals to diagnose and classify mental disorders.

Published and designed by the American Psychiatric Association (APA), the DSM is also used, I understand, for seeking mental diagnostic criteria to assure reimbursement.

The DSM is organized partially by the following:

I- Mental disorders
II- mental conditions
III- Physical disorders/syndromes, medical conditions (co-morbidity)
IV- Mental disorder suspected etiology
V- Pediatric assessments

The APA has historically directed the creation of each edition of the DSM, and assigns selected task force members to create this manual. This situation has proven to be controversial.

The next DSM involves 27 people. About 80 percent of these individuals are male, and only 4 members are not medical doctors.

Most have had relationships with the NIH, and about 25 percent of these task force members have had relationships with the WHO.

Historically, at least a third of task force members have had, or do, have often monetary pharmaceutical industry ties in some way.

Presently, greater than fifty percent of the task members have pharmaceutical industry ties.

This makes sense, as about one third of the APAs total financing is from the pharmaceutical industry.

The APA required this task force for the next DSM edition to sign non-disclosure agreements- which is rather absurd and pointless.

Lack of transparency equals lack of credibility because of these agreements of the content of the next DSM. It opposes any recovery model necessary regarding such disorders, I believe.

The DSM should be evaluated by another unrelated task force or a peer review of sorts to assure objectivity.

This is particularly of concern presently, as many more are diagnosed with mental dysfunctions presently at a concerning rate- with very young children in particular.

www.dsm5.org

Dan Abshear

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Diagnosing is tricky and depressives are even trickier. The DSM can and should be continually added to or altered as we learn more of the secret world of depressives. Young depressives act differently then older ones and older ones act differently then episodic ones and episodic differently the Psychotic ones. The DSM it should be noted covers all states of altered consciousness. Sincerely,David

The DSM is an attempt to determine if certain conditions are far enough from the mean and destructive, or potentially destructive, to merit treatment. It is commonly observed that numerous individuals exhibit bitterness or the closely related anger, etc.,to a degree which is well outside the normal distribution and/or grossly out of proportion to their real hurt. Whether the diagnosis will produce effective treatment, other than tranquilizing, is another problem.

First of all, let me put Otto Rank's notion of "birth trauma" once more to the same rest that Freud put it eons ago:

"Similarly, psychologist Otto Rank (1929) suggested in his theory of the "birth trauma" that the experience of birth is a traumatic tearing away of the child from the idyllic womb into a strange, hostile environment, and that the child naturally feels great anxiety and resentment toward the mother for this precipitous expulsion from Paradise."

As it passes through the birth canal, the fairly insensate infant is given a massage that is anything but traumatic. Actual birth traumas relate to strangulation by umbilical cords, unusual happenings - how would Darwin arrange it otherwise!

Persistent bitterness and rage can be morally and spiritually a good thing when it comes to objecting to "morally objectionable" matters such as Bush presidency which, at a Nuremberg tribunal, would result in execution for him and his vice-President and his first SecDef, I nearly said McNamara, but mean Rumsfeld; as compared to the utter indifference of the morally entirely slothful, the go-alongs, the passive. But it is indeed a fine line, between the kind of pathological bitterness that cannot change no matter the immediate personal or social circumstances, which keeps reproducing itself intra-psychically no matter what; which is impervious to sunshine. However, let me put it this way: what to you say to the inmates at Auschwitz? Hey, you're alive, you mother may have gone up the smoke stack, you might just not? Angry? Go kill a Kapo! Western capitalist class society with its value on "making it" is bound to generate an immense amount of rage! More pastoral societies do not.

Psychology Today in 1977 said I may be at that time a 1% in North America on a sociological scale. At 57 I find myself unemployed after 18 1/2 years daily caring for my lobotomised Mom, with acute awareness of life skills I simply didn't know I'm badly lacking. From my perspective a diagnosis of embitterred post trauma could enable me to acquire a better income as my job prospects are dimmed by the three years full time helping at Mother's nursing home. I learned family values but not tidiness, and find myself coping less and less with no where to turn and little to do but read want ads and look forward to minimum wages should I get lucky and score something to do for a wage. diagnosis isn't easy to find.

I am worried that the profession of psychiatry has lost sight of the person as a whole. I certainly recognize that we need diagnoses that are accurate and that we can agree on but the trend to reduce the individual to a basket full of labels dismays me. When med students and residents rotate through our office, they are very focused on establishing the list of diagnoses that apply to each patient. They are not focused enough on engaging and understanding the person in front of them. I have written more about this on my blog dated 6/18/09. www.cleveland-psychiatrist.com/blog.

Thanks for your comment. I agree with you. It is ironic that, in the context of these postings, I seem to be perceived as an enthusiastic supporter of the medical model's rampant tendency to reduce patients to a biochemical collection of signs and symptoms. I do not support such reductionism at all. Especially in psychiatry and psychology, that is a gross misuse and misunderstanding of psychodiagnosis. As one of my mentor's, existential analyst Rollo May observed, when we perceive the patient as merely an assortment of drives, symptoms, complexes and deterministic biological or environmental forces, we are losing the existential reality of the person him or herself. We are relating to the patient as a mechanism instead of as a human being. This is a tremendous problem in psychiatry and psychology today. But the solution to this dilemma is not to simply forego the diagnostic process, which can provide valuable information to the clinician regarding appropriate treatment. For example, if Post-Traumatic Embitterment Disorder becomes a formal DSM-V diagnosis, this might force mental health professionals to recognize, acknowledge and address the underlying role of reprressed anger or rage in many mental disorders such as PTSD, depression, bipolar disorder, and even certain psychotic disorders. Drugging anger and rage (the daimonic) is not the answer. Confronting it therapeutically is. Post-Traumatic Embitterment Disorder would be a small step toward recognizing the pervasive problem we have today regarding the mismanagement of anger in our culture, and its psychiatric consequences. Indeed, the controversy has already fostered further conversation about the phenomena of anger, rage and resentment among clinicians, which is long overdue.

Where's the evidence that expressing repressed anger and rage heals psychosomatic disorders? I've had one for almost 8 years now.

I remember taking up anger redirection on my own and hitting a punching bag everyday a few years ago while thinking about people or past events (current events too) that make me angry. After a few months of doing that I just got worse physical symptoms actually, not better. So from my own experience of implementing some kind of anger expression, it just makes a person worse. Or made me at least worse.

What your are describing is simple ventilation of anger, which is not what I am advocating. As Rollo May put it, such ventilation is more masturbatory than procreative. Meaning that it's not truly therapeutic or transformative--though it may be momentarily cathartic. It doesn't really change anything. And, indeed, it can fan the flames of anger and exacerbate any anger-related symptoms. Repressed anger must first be made conscious, understood in terms of source and to whom it was originally directed, fully experienced in the present, and used to change one's life in some constructive way. Anger is a powerful energy, and can be both destructive or creative. We need to learn to consciously redirect that daimonic energy into constructive activity and creative self-expression. Anger can be a kind of strength, even courage. Having said that, I can't speak at all to your particular "psychosomatic disorder," nor whether it was anger related or not.

...that Christopher Lane would actually consider learned opinions on a subject he knows nothing about? Waste of time! The man has a problem. Serious problems. He's a menace to serious discourse and has no business writing word one on mental health.

If drugs are "insufficient to the task," why are they the FIRST treatment mentioned?

Pushers, one and all.

Some years ago, I wrote this:

I have come to recognise a ‘syndrome’ that has features that are parallel to PTSD in respect of the DSM IV criteria.
1. The client has experienced events and relationships that are interpreted as a serious threat to their integrity by a system that the client believes is malign (if not malevolent), incapable of change and incapable of understanding the client’s feelings.
2. While the client does not have ‘flash-back’ re-experiences of a single event, the client is pre-occupied by the sequence of events and the situation and is constantly ‘reliving’ and rehearsing it in their thoughts.
3. The client avoids any kind of contact with the people associated with the events, those with whom relationships have broken down and those considered to represent ‘the system’ and may avoid things like an occupational health consultation that are perceived as possibly a step on the way back to the resumption of contacts. This avoidance may cause the loss of any understanding that ‘the system’ may be persuaded to exhibit by (for example) an occupational physician.
4. The client experiences persistent symptoms of dysphoria that may include anxiety, irritability and depression, a spreading mistrust that may verge into paranoia, sleep disturbance, etc.
As with the criteria for PTSD, I think these features constitute an entity meriting consideration if they persist for more than a month.

I have shared this with Dr James Briscoe, a psychiatrist specialising in occupational mental ill-health. He wrote:-

“I quite agree with you that this entity exists and you have described it extremely well. I think some of the other specific symptoms that are described frequently enough to merit diagnostic validity are people experiencing a dread of returning to work and symptoms of hyper-alertness, particularly when the telephone rings. There is also an avoidance of opening mail or responding to telephone calls. An early symptoms appears to be a lack of self-confidence.

“Although you have associated this with the diagnosis of PTSD in respect of DSM 4, if you consider the ICD 10 classification, the nearest one can get to this “syndrome” is Adjustment Disorder. Unfortunately, the advice that is given to Occupational Physicians is that Adjustment Disorder does not warrant ill health retirement. However, in my experience, by the time employees end up seeing me they have progressed from Adjustment Disorder to either a specific Anxiety Disorder such as Panic Disorder or Generalised Anxiety Disorder, or a depression of moderate severity.

“I believe that one of the great failings of the present system of assessing and dealing with people who show signs of this “syndrome” is that it is not widely recognised as being as disabling as it clearly is and without a recognised validated diagnostic category it makes it more difficult to put the case for ill health retirement, which is often based on diagnostic fit.

“As far as I am aware, and I do not by any means have an exhaustive selection of research in this area, this “Syndrome” has not been described as an entity in itself, particularly in relation to work. If you are interested I would be very pleased to discuss with you the preparation of a description of this “syndrome” in more detail, and contribute to what I think will be an interesting debate about stress at work, its sequelae and the interface between recovery and enduring, on-going symptoms.”

As is often the case with busy people, though I requested an appointment for a discussion, this never happened. However, I have a collection of half a dozen case descriptions that fall into this category. I should be very interested to have views on this “syndrome” and any anonymous case reports that illustrate it.

The "syndrome" you describe is very commonly seen in Worker's Compensation cases, and it is indeed quite debilitating. The DSM-IV-TR diagnoses made in such cases typically include Major Depressive Disorder, Single Episode, sometimes accompanied by an anxiety disorder. Adjustment Disorder with depressed features is also used by some clinicians in these cases, but I agree that this diagnosis does not reflect the true severity of this syndrome. You are describing here a syndrome which meets many of the diagnostic criteria Dr. Michael Linden proposes for his Post-traumatic Embitterment Disorder--without the embitterment! But I suspect the embitterment is present in most of these cases you describe. And, if so, that would be another good reason to support the inclusion of PTED in the revision of the forthcoming DSM-V.