I appreciate this opportunity to respond to the thoughtful presentations of Drs. Harold Kaplan and Oscar Legault in the previous issue of The Newsletter regarding the developments surrounding the Third Edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III). I particularly appreciate the spirit in which their presentations were made, in that they lacked the name calling and uninformed accusations that have characterized some discussions of DSM-III.
Perhaps the greatest concern that many psychoanalysts have regarding DSM-III is that the concept of what is a mental disorder will be so narrow as to exclude individuals who would be considered ill using psychodynamic concepts. Undoubtedly, the controversy regarding the deletion of homosexuality from DSM-II provides the initial basis for this concern. Space does not permit a full discussion of how our thinking has evolved and changed over the last two years, however, let me briefly indicate our current thinking on this very complex issue.
It is unlikely that DSM-III will provide a comprehensive definition of what is and what is not a mental disorder. An attempt on my part to do so at the last annual meeting of the American Psychiatric Association was widely received as being more harmful than helpful. Nevertheless, by examining the definitions for the various DSM-III categories, certain general principles are evident. By and large, all of the categories included in DSM-III are conditions which, in their extreme or fully-developed form, either cause subjective distress, impairment in social functioning, or put the individual at some intrinsic disadvantage compared to individuals who do not have the condition.
This general principle affects the definition of various categories in the following ways. Personality disorders are distinguished from personality traits (which are not considered disorders), in that for the disorder to exist, it must either cause subjective distress or interfere with functioning. We recognize that frequently patients with personality disorders do not complain of subjective distress, but we would argue that in such instances, for the disorder to be present, there should be evidence of some interference in social functioning. (The careful reader of Dr. Kaplan's presentation of the material from the St. Louis Conference will note a contradiction. Dr. Kaplan reported the DSM-III criteria for personality disorder as requiring both subjective distress and impairment in functioning. Unfortunately, the individual who presented the DSM-III material on personality disorders incorrectly said, “and” instead of “or” when presenting these two criteria.)
All of the traditional sexual “deviations” are included in DSM-III, except that homosexuality is not included unless accompanied by subjective distress, and the condition is then termed Sexual Orientation Disorder. However, with this exception, all of the other traditional sexual deviations are included without any requirement that they be accompanied by subjective distress or impairment in social functioning. Certainly, conditions which require a non-consenting partner, such as exhibitionism, voyeurism, and sexual sadism, place the individual at an intrinsic disadvantage, since no society can generally tolerate such behavior. Thus, whether or not accompanied by distress or impairment in social functioning, these conditions meet our criteria for a mental disorder.
I hope that the above remarks clearly indicate that the issue of egosyntonicity with regard to the diagnosis of the “perversions” (and the sexual dysfunctions, by the way) is not “still up in the air,” as reported by Dr. Legault in his article. It is a little disconcerting at this late date still to be reminded of a foolish provisional approach that we took, which was widely publicized in a June 1975 Psychiatric News article, when shortly thereafter we have consistently taken the position described above.
Dr. Legault states that our attempts at a “quasi-behavioral definition of mental disorders runs into the difficulty that a number of conditions which many psychiatrists, and certainly most psychoanalysts, would regard as disorders, do not fit this behavioral definition.” I understand our differences with regard to homosexuality per se, but I would like to know to what other conditions he is referring that would not be considered mental disorders in DSM-III? Dr. Legault states that our approach fails to recognize that “the function of defense is to render even serious psychopathology egosyntonic, adaptive and nondisabling.” I find it difficult to understand a conception of serious psychopathology that involves behavioral consequences which are entirely “adaptive.” Surely, in all serious psychopathology there must be some loss of pleasure or some other functional capacity which then puts the individual at some disadvantage compared to other individuals who do not have the pathological condition (one of our criteria). If the consequences of the internal conflict are entirely adaptive, why is this not a healthy resolution of the conflict?
Finally, one last remark on another aspect of DSM-III which is very upsetting to many psychoanalysts: the deletion of the category
of neurosis as a classifying principle. To simplify another very complicated problem, the major reasons for grouping the traditional neurotic subtypes in other rubrics (e.g., anxiety disorders, hysterical disorders, and affective disorders) rather than in a single rubric (“the neurosis”) are twofold: First of all, the neurotic process of compromise formation to an internal conflict is not limited to the traditional neurotic subtypes and can involve other disorders (which did not appear in DSM-I or II, such as various sexual dysfunctions or anorexia nervosa. Secondly, for a variety of reasons, we believe that mild depressions (“neurotic depression”) are not always the result of a neurotic conflict and therefore are best classified on the basis of clinical phenomenology within the broad group of affective disorders.
I look forward to further input into DSM-III from the American Psychoanalytic Association. By the time that this is published, the American Psychoanalytic Association will have received an invitation from our Task Force to set up a liaison committee critically to review DSM-III and make suggestions for its improvement. I heartily agree with Dr. Kaplan's closing remarks: “The problem of classification of Mental Disorders is most complicated, and the openness of the (St. Louis) Conference (on DSM-III) left me with the feeling that reasoned scientific suggestions will be seriously considered.”
—Robert L. Spitzer