What We are Getting Wrong About Mental Illness: Diagnostic Manuals are BROKEN

Uploaded 4/23/2023, approx. 31 minute read

A proper diagnostic manual should closely adhere to or conform to the lifespan of the individual.

More precisely, the life of the brain.

Because we inhabit our brains exclusively. Our brain is a paracosm, an alternative virtual reality within which we subsist. We are creatures of dreams. We are addicted to narratives.

And our brains constantly scour reality for hidden texts or vertex, subtext, pretext. It's all about text.

So we write reality. We offer it as we go along, crawling through the path of our life. We reconstruct even our memories on the fly.

We are not an immutable objective entity, somehow measurable. We are not. We are fluid. We are like a river.

And any diagnostic manual that consists of lists and categories is a fantasy. It's delusional. It doesn't capture 10% of what it is to be human. And isn't psychology, even clinical psychology, the study of what it is to be human?

Well then, if it is, the DSM and the ICD are both colossal failures.

A proper diagnostic manual, in my view, should be divided in three parts.

People describe mental illnesses, mental disorders, mental dysfunctions and disturbances.

No doubt about this.

But divide them in three parts.

In close adherence to the developmental path or developmental journey of a typical healthy, normal human being.

So the first category should be brain abnormalities that generate mental illness.

Because that's how we start with the brain. We'll discuss it in a minute.

Second part of such a diagnostic manual should describe or list relational, societal mental illnesses.

Because that's the next phase, starting with puberty, adolescence, we develop extended object relations. We begin to relate to other people. And we become relational creatures.

There's no such thing as an individual. It's nonsense. It's an idealization. It may be comfortable, maybe convenient in textbooks. But in reality, there's no such thing.

We are all the outcome of intersections with other people. We are like Venn diagrams. The shaded area is us.

And so this would be the second group of mental illnesses, relational, interpersonal, societal.

And the third group would be innate, innate mental illnesses.

These are mental illnesses that manifest much later in life and are somehow connected to the process of aging or at least the process of growing older or old.

Such a diagnostic manual would be a lot more useful than what we have today. And what we have today is a hodgepodge and a mishmash of schools of psychology, observations, debatable conclusion based on puny studies, the influence of the pharmaceutical industry and the insurance industry in the United States mainly, the effects of clashes of cultures and civilizations.

So we have many culture-bound syndromes. It's a mess. It's a mess because ultimately a diagnostic manual should be about one thing only, one topic only, you and me.

That's it. We are and should be the core of any diagnostic manual.

So what can we say about us with any certainty?

Start with what makes us to a large degree human, the brain.

The brain is a magnificent creation. Can easily be described as the crown of lifeand possibly the crown of the universe itself. It's very unlikely that aliens out there would be brainless. They would have something the equivalent of a brain.

Richard Dawkins had written a book, I think it was 1974, if my memory doesn't fail me or 1976and it was called The Selfish Gin. He would have called it The Selfish Brainand he read the second edition, 2014, of Sue Gerhard's masterpiece of popular science, Why Love Matters. It's a neat summary of what had been known at that time, eight years ago, nine years ago, what had been known about brain formation in early childhood, the various effects and reasons for how our brains shape up to be.

Our brains are a work in progress well into our 25th year of life.

Only by age 25 do you have a fully formed brainand your brain remains neuroplastic for the rest of your mortal coil to the very last second of your lifeand even when you are in the process of dying, that's near death experiences.

The brain is in action throughoutand your brain is not only a window to the world, it's also a filter of the world.

It's a membrane in effect. It's a membrane. It's a series of algorithms embedded in raw material, in carbon, series of algorithmswhich teach you or help you process reality in a way that will not be too injurious on the one hand and will aid and abet survival on the other.

It's a fine, delicate balancing act, very delicatebecause when the brain gets it wrong and shields us from reality too much, we become mentally ill, we become delusional, psychotic, narcissistic.

At that stage, the loss in reality testing cannot be compensated for in any other way, cognitively or emotionally or otherwiseand then having lost touch with reality, we are doomed. We are doomed.

Our survival is at stake.

So on the one hand, the brain needs to maintain an amicable relationship with our reality.

On the other hand, reality is painful, hurtful, injurious, frightening, destabilizing.

The brain needs to protect us from reality, to somehow reshape it and reframe it and play with it, to render it palatable and acceptable and workable to us.

And it is this delicate balancing act, this homeostasis, this equilibrium between denying reality and accepting reality, gaining access to reality while avoiding reality.

This is the main work of the brain, if not the only work of the brain.

Brain processes, sensor, sensory inputs, arranges them in narratives, predetermined narratives based on memories and some kind of core identityand then serves this dish cold so that we can consume it without suffocating on it.

This is the brain's main task.

At night, when we sleep, the brain rearrangesmemories, fears, cleanses itself, physiologically, by the way, the spinal fluid that courses through the brain and cleanses it.

And the next morning, it's ready to goyet again, isolating us from reality, but not to the extent that we would be in danger.

Babies are born prematurely. They're born with their brains half formed.

The speculation is that babies are born that way to allow the skull of the newborn to pass through the birth canal.

Maybe, probably actually, the human skull, the baby human skull is the largest in the mammal kingdom.

So babies are born prematurely. Their brains are half baked, half formed.

It is the role of the maternal figure, typically the mother, to facilitate the maturation of this magnificent organ via tactile stimuli, touch, sense, speech, and above all, good enough mothering, affection, love, a modicum of idealization.

Mother is the primary filter of the world.

The child processes the world in reality initially through the mother, which is why children, I mean babies up to six months old, can't tell the difference between themselves and mother. They're one and the same. It's a symbiotic phase. They're fused. They're merged. And so a good mother helps mold her newborn's brain to the point that it can take on the world.

It can begin to process reality without her intermediation and agency.

Putting the finishing touches on our brains is our main and only undertaking in life.

We are nothing but project brain. We are servants to our brains.

Our brains use our bodies as containers and ATMs and supermarkets. Our bodies are there just to serve our brains.

Telling to our twenties, our brains are mutable, they're shape-shifting, they're changing all the time. They're unrecognizable from one year to the next.

Ask any parent of an adolescent.

In effect, what happens during this period in life, we grant access to other brains.

We grant this access so as to form cerebral networks, networks of brains.

Brains collude with brains, collaborate with brains, communicate with brains, coalesce with brains.

These are cerebral networks, family, friends, peers, teachers and role models.

Our brains apart, as I said, our bodies are incidental until we are ready and fit to procreate.

Every then our bodies attain a modicum of priority.

But initially it's all about our brains.

Teenagers, for example, are reckless. They don't care about their bodies. They realize somehow intuitively that their bodies don't matter.

So in the initial phase, the formation of the brain throughout toddlerhood and babyhood and childhood, it is then that certain brain abnormalities come to the fore.

Brain abnormalities that later translate to mental illnesses.

And this should be the first section of any proper diagnostic manual.

And then we grow up, pubertybecome adolescence, and we begin to interact with other people.

But relations takes off, take off.

And so we form these what I call cerebral networks or brain networks.

Now there are again abnormalities and dysfunctions and disruptions in disorders, of course.

And these are the societal relational disorders.

During this period of late childhood and adolescence and well into young adulthood, we undergo the twin processes of socialization and acculturation.

We imbibe and assimilate the mores, conventions, values, beliefs and narratives of our respective society and culture.

This is done not directly, but through the intermediary of socialization agents, most notably parents, teachersand influential peers.

And all this process is totally nodal, totally networked.

This is why the influence of peers during teenage years is disproportional.

Because peers part and parcel of these emerging networks, ad hoconthe flying networks very often, but still networks.

That's the organizing principle of this period in life.

The organizing principle of the first period is solipsism and grandiosity.

The baby believes himself to be the world. It's a bit psychotic, if you wish.

The baby is psychotic. He believes himself to be one with mother and then one with the universe.

Baby develops grandiosity. He becomes grandiose enough to take on the world all by himself, all by his puny self.

It lets go of money in the separation and individuation phase.

The first phase, brain formation, solipsism and grandiosity.

Second phase, brain networking.

And in this phase, we develop empathy. We develop social skills. We internalize society's values, beliefs and narratives, socializationand the more is an edict of our dominant culture, acculturation.

This stage, there are mental illnesses that reflect a disrupted process of socialization and acculturation.

And the exposure to socialization and acculturation agents which themselves are mentally ill.

If you are, if you are the offspring of mentally ill parents, you are much more likely to be mentally ill.

This is the statistics.

So the second part of the diagnostic manual should be dedicated to these relational, societal, mental health disorders.

And shortly I will discuss the second part of this video, I will discuss psychopathy.

Psychopathy is a prime example of this kind of mental health disorders.

It's not a clinical entity, the sense that in my mind, it's not a mental illness. It's not about the individual, the psychopath.

There's nothing wrong with the psychopath as an individual. There's everything wrong in the psychopath's ability to relate to other people, to see other people, to empathize with other people, to put himself in other people's shoes, to restrain himself and control his impulses in order to not harm or damage or break other people.

What's wrong with the psychopath? What's wrong with the narcissist?

In some extent, with the borderline, with the paranoid and so on. What's wrong with these people, schizoid? What's wrong with all these people?

It is not innate, it's the breakdown of interpersonal communication and interaction. It's relational.

And then we come to the third phase of life from, let's say, age 25 to age 85, essentially, and that's adulthood.

Adulthood involves the unwinding. It involves regression. It involves the unwinding of these earlier promiscuously open cerebral networks.

You remember that in the middle phase, let's say between six and 25, we form brain networks. We interact with people, friends, family, peers, etc. We open our minds. We allow access to our brains, sometimes direct access. Our brains are being shaped by these interactions.

Object relations, if you want to use the antiquated 1960s term, object relations shape our brains.

So our brains become through networking. Our brains get immersed and embedded in gigantic networks of influence, information and interaction.

As adults, we unwind these networks. They're too promiscuous. They're too open.

Consequently, they're too risky. The brain is firewalled during this third phase of life. It's firewalled. It's fortified by reality, reframing and filtering.

The brain develops defense mechanisms, narratives. The brain creates all kinds of other types of protections, behavioral protections, mainly heuristics, rules of thumb, principles of action. The brain isolates us within a fantastic fictitious space with its own rules, its own dimensions, its own regulatory mechanisms. Embedded or captured actually, within the prison of our own minds, we gradually drift apart from others and cut them off.

We're beginning to perceive other people as costtobenefit ratios. We begin to realize that opening ourselves up to other people has its dangerous and attendant risks. We begin to be a lot more avoidant, a lot less reckless, a lot more cautious and consequently a lot more isolated.

This firewall, the brain hides behind these fortifications. It becomes a fortress.

And the brain, this stage, is busy filtering out reality, reframing it in short line to us, confabulating, prevaricating, rendering reality more acceptable, more livable, more tolerable, more bearable, less terrifying. The brain is busy all the time. We're specifying reality to allow us to survive.

The irony is that we've been exposed to reality exactly as it is, we wouldn't survive 10 minutes.

We all survive within a fantastic inner space which has little to do with reality.

You should read the studies by Elizabeth Loftus.

Studies about memory, these are early studies about memory. They're shocking, absolutely shocking.

We don't have memories.

Consequentlyour identities are total pieces of fiction. Our identities are movie scripts, they're not real.

We're all fallacious. We all lie all the time about who we are, where we are going, where did we come from. We reinvent our past and imagine our futures.

Emotions and cognitions begin to mediate our experiences. Emotions and cognitions are amenable to manipulation, change, syllogistic, tackling. Cognitions are open to interpretation, embedded in formal and informal systems. Emotions are forms of cognition. They inform us and they're bad advisors usually.

And so the cumulative hurts, the pain of existence, the anxiety, the angst of having to make choices every single second of our lives, choicesthe outcomes of which are indeterminate and uncertain and therefore threatening and ominous and menacing. These burdens cause us to withdraw.

The third phase of life after age 25 is about withdrawal and avoidance and constriction.

We become increasingly more solipsistic with age.

This culminates of course in the ultimate schizoid state, death.

The third part of any proper diagnostic manual should describe mental illnesses that emerge during this desperate attempt to detach from reality and from others.

Mental illnesses which are essentially innate reactions to the dissolution of the cerebral or brain networks of phase two and the challenges to the grandiosity and solidism of phase one.

The defenses of phase one and the defenses of phase two survive into phase three, but they are no longer viable. They're no longer viable because we forgo, we give up on contact with others and with unmitigated, unfiltered reality.

We feel more and more comfortable within the confines of our mind.

And so we have to give up. A larger and bigger share of our lives hitherto.

And at that point there is dissonance.

Because this transformation is so huge that we feel alienated and estranged throughout the rest of our lives.

And to protect us from this alienation, estrangement, the brain surrounds us with a storytelling environment, creates for us a fiction or a narrative ecosystem within which we can survive.

Stories we tell ourselves about ourselves and others and the world at large and our affiliations and beliefs and religions and you name it, some stories.

We die for fiction. People die for the nation.

What the heck is a nation?

We talk about racism, there's no such thing, biologically at least.

This is all fiction. We become fictional characters.

It's not easy to denude ourselves of corporeality, to let go of our being as physical objects and to convert ourselves into obstructions, symbols within our own minds, a self-referential, introspective infinite loop.

In this process many things can and go awry, do go awry.

This infinite loop that I mentioned can become obsession and compulsion.

The inability to avoid or withdraw from reality can become psychopathy, antisocial behavior.

The fictitious narrative that our mind creates for us in order to protect us from the vagaries and challenges and hurt and pain in reality could become narcissism.

Some of these are relational societal disorders which are only magnified, but some are innate disorders.

Some of the disorders in the third section of any proper diagnostic manual, the disorders of the third phase, the adulthood phase, should be mostly innate.

These are rebellious reactions or panic reactions against the processes we are undergoing.

Reactions such as schizoid states, reactions such as anxiety and depression, reactions such as substance use, these are all innate mental health illnesses, disorders and behaviors that are intended initially to let us cope with the third phase but then go out of hand and out of control.

So to summarize, three phases of life, three parts of a diagnostic manual.

First phase, totalhood, childhood, solipsism, grandiosity, taking on the world as the brain evolves and forms until it becomes mature at age 25.

During the initial phase, childhood, there are disorders of the brain, brain abnormalities.

So the corresponding part in the diagnostic manual would be brain abnormalities.

The second phase, we create brain networks.

We open up our brains, unprotected, unfiltered, unmitigated, unisolated.

We connect promiscuously, openly, directly, immediately.

This is the phenomenon of peer groups in adolescence and our brains flourish and mature in reaction to the contribution from the other nodes in the network.

So this is a networked environment.

During this phase of socialization and acculturation, a failure usually owing to deficient socialization agents would lead to relational and societal and culture-bound disorders such as narcissism or psychopathy, antisocial disorder.

So this is the second part, the corresponding second part of the diagnostic manual.

Finally, from age 25 until we die, adulthood, we withdraw from the world, we filter reality, we create narrative defenses, we reframe everything, we protect ourselves against the hurtful incursion of the world.

At this stage, there are innate, innate disorders, reactions which are adverse and adverse, reactions which are the outcome of an inability to complete these processes of withdrawing into a fantasticparacosm state, into a story, into a movie.

And this is the third part of any proper diagnostic manual, the innate disorders of adulthood, culminating in the ultimate withdrawal from the world, death.

Nowthe second part, I'll deal with psychopathy.

The third part, I'll wrap up and suggest a structure for a future diagnostic and statistical manual of international classification of diseases.

There's a lot of work to be done first and foremost to determine whether we should establish a whole class of social relational mental disorders.

Narcissismfor exampleis a relational disorder.

Psychopathy and antisocial personality disorder, these are societal disorders.

It's not a shame, it's not shameful to say, it's a group of disorders which have to do with brain abnormalities, for examplebipolar, psychosis, schizophrenia. There's a group of disorders which are innate and reflect mental illness.

Again there is a group of disorders which erupt and occur only when other people are present, only in interpersonal and societal settings. This group of mental illnesses should be separatedeven in the DSMunder the heading of societal, cultural and interpersonal relational mental health disorders.

Until about a hundred years ago, this was the case.

Many mental health disorders were described as character disorders.

We need to determine the full extent of this alleged disorder in various subpopulationsfor example. We need to determine the clinical picture in womenfor example. Of course, outcome, we don't know any of this.

There's a small percentage of people with ASPD that have no precursor, have no history of contact disorder. How come?

We need to characterize this subset.

We need to use much bigger samples.

We say that the disorder is chronicbut why? Why do some people improve while others do not, even though we know the predictors, we don't know the process. We don't know if therapeutic interventionsfor example, incarceration, how do they change the course of ASPDif at all? Outcome predictors are importantof course, clinical, illness variables, potential biomarkers, everything, yeahsure.

But if this is a disorder of childhood, we must focus on troubled children.

They are at the greatest risk of developing ASPDand children go through the process of socialization, they are in the throes of becoming.

So these are disorders of becoming.

Something goes awry in transitioning from tabula rasa to individual. Everything again is not as it should be in the process of individuation.

We need to focus on this.

We don't need to pay so much attention to criminals in prison populations. There was a wrong orientation. It led us astray.

We wasted decades.

Of coursesome people got rich in the process, names withheld. But it led us astray.

We need to realize that disorders like ASPD reflect a child's inability to internalize socialization.

And a child is unable to internalize society and its signals and messages and values and core and conventions and mores.

Child is unable to internalize all these because there's something wrong with the socialization agents.

His parents, his peers, his teachers, his role models. Something's wrong with them. Something goes awry.

The acculturation and socialization processes in these children, they just don't learn how to be social beings.

It's not so much as antisocial personality disorder. It's like non-social personality disorder.

These children become adults who go through life doing whatever the hell they want. They don't realize the interplay between society and individual.

This is what we need to focus on.

Not on measuring all kinds of nonsense in prison populations or people hospitalized in mental asthma. We won't get anywhere with this.

Because these people are finished. They're ready-made. They're made.

They're not going to reverse. They're not going to regress. They're not going to change.

So why study the unfortunate outcomes and not the process that leads to the outcomes and give us hope of treatment?

And yes, of course there is hope of treatmentif we care to find out what causes this disorder, including the possibility that there are brain abnormalities and so on.

When it's a chick in the neck, was the brain abnormality caused by the disruptive process of socialization or did it cause the disruptive process?

I opt for the first.

I think the brain abnormality is a secondary, not primary.

But this also needs to be provedor at least investigated.

We have a lot of work to do. Eight years later, shame on us.

And today we're going to discuss antisocial personality disorder psychopathy.

Are they real? Is there such a thing? And if they are real, how to become one?

You can't say you're not having fun with some wackne.

Okay, social name, shvanparnim, khabrivim, kmadmadim, maddanim, pashroshik, gontask.

The list is way too long, even for my 190 minimum IQ.

The problem with antisocial personality disorder, as it is defined in the Diagnostic and Statistical Manual, edition four, text revision, edition five, text revision, is that the diagnosis relies on criteria which are behavioral.

In other words, to qualify to receive a diagnosis of antisocial personality disorder, you must behave in certain ways.

The criteria are not based on anything intrinsic. They're not even based on any clinical observations. They're based on behavior, personal history, autobiography.

And this raises the question, if you behave in a certain way, does that make you mentally ill?

For example, if you hate authority, aka, contumacious, if you are defiant, if you are reckless, if you don't care for the consequences of your actions, if you reject your life, if you're violent and aggressive, if you are pathological something, a pathological liar, a pathological gambler, if you lack impulse control and behave in ways which are deleterious and detrimental to other people.

It's all bad, of course.

But does that make a mental illness? Shouldn't a mental illness be a clinical entity? Shouldn't it be almost medical? Shouldn't we be able to diagnose mental illness regardless of specific socially rejected behaviors? Aren't we pathologizing socially unacceptable behavior? Aren't we pathologizing a refusal to sublimate, a refusal to play by the rules of society? Aren't we encouraging conformism, sheeple mentality?

In short, isn't the diagnosis of antisocial personality disorder, isn't it a form of social control? Isn't it an instrument to subdue and subjugate the wayward, those who don't play by the rules, those who don't obey the law, those who reject and resent authority, those who undermine the pillars of our civilization, those who challenge social mores and conventions, those who are mavericks and even entrepreneurial in many ways?

Why do we pathologize them? Isn't it a tool of society rather than a proper clinical entity?

I personally happen to think that antisocial personality disorder is BS. It's not a mental illness. It's not a diagnosis. It should not be a diagnosis. It should vanish.

In my view, it's completely wrong. I think it's what we call a culture-bound syndrome.

In other words, a set of traits and behaviors that we find reprehensible, that society frowns upon, that we would like to eliminate and eradicate because people get hurt or damaged or broken.

But the proper place for this isn't criminal courts, not in diagnostic manuals.

And when we start to mix it or confuse it or to mix it or to conflate it to the criminal system and the psychological system, what we get is dictatorship.

In Soviet timesin the USSR, dissidents, people who oppose the regime, they were diagnosed as mentally ill and they were placed in mental asylum for the rest of their lives.

We are going that way.

There are hundreds of thousands, if not millions of people in prison just because they don't agree with the rules and the laws of society.

Now, many of them spend time in prison only to find out they never write.

For example, homosexuals were incarcerated. Homosexuality was a crime for well over 300 years in multiple locations, including very civilized places like the United Kingdom.

It's not a crime now. It's not even a mental illness. It used to be a mental, it used to be homosexuality, used to be defined as a mental illness until 1973, the DSM-3 removed it.

So people who, for example, smoked cannabis or marijuana, they went to prison only for the laws to change. Laws are not written, are not cast in stone. Laws don't come from high up. Laws are human inventions. Laws reflect ever shifting consensus.

So to create a mental health diagnosis based on behaviors that are today unacceptable and tomorrow mainstream, that's crazy and undermines the objectivity and foundation.

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