Fear is not a Mental Disorder: Or What is Really Wrong with the DSM

As the American Psychiatric Association (APA) prepares to publish the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013, there has been considerable debate about the changes in this document. Client advocacy groups and professional interest groups have stated many objections to DSM-5, with most complaints focusing on specific changes in diagnostic criteria, on placement of diagnostic categories, or on inclusion of diagnostic categories or criteria. Specific complaints about the diagnostic categories include:

  • Asperger’s syndrome should not be on the autism spectrum
  • the addition of disruptive mood dysregulation disorder (DMDD) may pathologize normal childhood temper tantrums
  • the definition of major depressive disorder should not be broadened to include normal bereavement

In addition, more broad-based, theoretical concerns have been expressed by such groups as the American Psychological Association’s Division 32: Society of Humanistic Psychology. In a thorough and thought-provoking letter to the APA in 2011, the group stated that, “it is time for psychiatry and psychology collaboratively to explore the possibility of developing an alternative approach to the conceptualization of emotional distress.”

The controversies surrounding DSM-5 have once again brought up a debate in the profession that the entire atheoretical construct of the DSM should be reconsidered from the ground up. Given the well-documented shortcomings of the DSM, I wholeheartedly concur and have written an essay titled Fear is Not a Mental Disorder The profession needs to move beyond arguing about minor reshuffling of diagnostic categories. These complaints may certainly be justified, but actually are just a rearrangement of the deckchairs on a poorly designed, poorly constructed, and doomed Titanic. The psychology profession must lead an effort to develop a new, improved, and fact-based diagnostic system that is more accurate, clinically useable, beneficial to clients, and provides an effective therapeutic framework.

I am a practicing clinical psychologist who for years has believed that the DSM is inaccurate and misleading in fundamental ways and could even be considered harmful to clients. The mythology of the DSM has for decades hindered therapeutic treatment of clients, and generally complicated what are very simple, understandable concepts that underlie human behavior.

I am not going join the argument of whether Asperger’s is or is not on the autism spectrum, or whether children who throw temper tantrums should be diagnosed with DMDD. Rather, this essay will take a broad, philosophical look at concerns about the DSM. I believe, as many do, that the time is right to completely re-conceptualize diagnostic strategies from the ground up, with the goal of developing a replacement for the DSM.

In Fear is Not a Mental Disorder, I present a powerful and concise theoretical framework to use when diagnosing human behavioral and emotional distresses. This new paradigm called Natural Psychology is explained in depth in my book Pack Leader Psychology. This paradigm offers numerous benefits not found in the DSM, corrects many of the theoretical errors in the DSM, and provides an effective diagnostic and therapeutic solution. And it does so in far less than the 943 pages of the DSM-IV-TR.

Natural Psychology is based on indisputable facts, not the unscientific, confusing, and complex “system” of “diagnostics” of the DSM. Most important, the Natural Psychology model brings numerous benefits to clients, whom we in the psychology profession are ethically bound to protect and help. Where the DSM pathologizes human behaviors as illnesses and disorders, Natural Psychology offers an innovative paradigm that explains these behaviors as normal, natural responses to perceived or real threats and fears. Natural Psychology is a more positive, optimistic, and straightforward framework that strips away harmful, judgmental labels and de-stigmatizes “mental illness” in a profound and fundamental way.

Quite simply, Natural Psychology is based on this concept:

The majority of “mental disorders” that people experience are due to the primal fear response. Fear is not a disorder, but a normal, adaptive human reaction.

I realize that criticizing the “bible” of the psychiatric profession may be sacrilegious to many, but I believe the psychology profession has a duty to serve clients. Keep an open mind as you read this essay. Remember that just because the DSM has an aura of scientific precision, does not prove that its ideas are valid. The DSM is published by a major medical organization and is loaded with technical language, complex numbering systems, obscure terminology, and weighs an intimidating three pounds, but that does not make its precedence unchallengeable.

The publication of the DSM-5 may the tipping point in a history of over-reaching and misinformation by the American Psychiatric Association, forcing the psychology profession to take action.

In Fear is Not a Mental Disorder I will discuss:

1. What is the DSM?

2. How the DSM ignores major psychological facts and concepts

3. A new diagnostic paradigm called Natural Psychology

4. 10 reasons why Natural Psychology should replace the DSM

I recognize these ideas are controversial, but please keep an open mind, click on the link to open the PDF and read the entire essay.   Then join me in a discussion about the DSM-5 and mental health diagnostics in general. I would LOVE to hear your comments.

PDF of Essay:  Fear is Not a Mental Disorder

Anxiety: An Evolutionary Approach Disses the DSM

With the Diagnostic and Statistical Manual 5th Edition set to publish in May, I have been doing a lot of research on the DSM and writing an essay on it (coming soon to a blog very near here!). I just finished an excellent book entitled, “All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders,” by Allan V. Horwitz, PhD, and Jerome C. Wakefield, PhD, DSW. I was intrigued by this book because the title seemed to parallel some of my theories in Pack Leader Psychology, that humans have natural fears and reactions to those fears. And one of my main complaints about the DSM is that is pathologizes what are actually normal, adaptive behaviors.

This book did not disappoint and I would highly recommend it to any clinicians interested in anxiety “disorders,” evolutionary psychology, the philosophy of psychology, or the DSM and its troubled history.The authors do a very thorough job of defining anxieties per the DSM and presenting a brief history of anxieties in the psychiatric field.

The meat of the book begins in Chapter 2: An Evolutionary Approach to Normal and Pathological Anxiety. (It’s not as dreadful as it sounds!  Actually, the book is quite readable and accessible, with a down-to-earth approach and tone.) This chapter has an excellent summary of five philosophical approaches to differentiating between “normal behavior” and “mental disorders:”

– Are disorders caused by brain malfunctioning?

– Are they the result of learned experiences (conditioning)?

– Are they defined by changes in social values (homosexuality used to be considered a mental disorder!)?

Are disorders defined by statistical rarity?

Are disorders judged as such when they are “clinically significant” or “impairing” to the patient?

After critiquing each approach, the authors offer an evolutionary approach to anxiety. (An approach I believe that also works for most other psychological “disorders.”) Quite simply: “Psychological functions arose to respond to prehistoric, not contemporary, conditions.” (p. 35)

Emotions developed over thousands of years of human evolution to help us survive. Each emotion has a natural function, with related physiological, psychological, and behavioral processes, to allow humans respond to social and environmental situations.

Fear helped us survive by sensitizing us to dangerous people or situations. It prepared us to attack or retreat, to placate a dominant tribe member, or taught us to avoid a dangerous watering hole or a poisonous berry. Considerable research has proven that we have innate fears of heights, snakes, spiders, darkness, strangers, public humiliation, and social ostracizing. These fears were survival enhancers when we lived in caves and tepees and with a small group of protective tribesmen.

Horwitz and Wakefield have irrefutable evidence, as well as significant common sense logic, that most anxieties, phobias, PTSD, and obsessions/compulsions, as defined by the DSM, are really normative, expectable reactions that should not be labeled as disordered. Horwitz and Wakefield note that today’s anxieties are “mismatched” with today’s environment. In essence, we are using primal survival emotions and behaviors to try to live in a world that is very different from our hunter-gatherer forebears. “Many natural fears are not grounded in responses to any current environmental danger but are manifestations of ancestral fear mechanisms.” (p. 76)

The book then goes into a history of anxiety diagnoses and the DSM’s changing definitions of and criteria for anxiety disorders, using their evolutionary perspective to point out inconsistencies and errors in logic.

For example, after explaining that fear of social exclusion is innate in humans and one of the strongest primal fears, they note: “Perhaps the oddest thing about the DSM-IV definition of social phobia is that it classifies as disordered those people who are afraid in exactly those situations in which fear is most natural… Unfamiliar people are inherently more threatening than familiar ones, and humiliation is a potent threat to people when others  — especially, say, their bosses or competitors — evaluate them.” (p. 132-3)

They then critique several large-scale studies of the rates of mental disorders in the population. Among other complaints, the authors note that the studies fail to take into consideration the context of a person’s anxiety. For example, studies of people following natural disasters or the 9/11 terrorist attacks found very high rates of “mental disorders” such as PTSD and anxiety.  “It is hardly imaginable that a clinician would consider ‘mentally ill’ a patient who has recently survived a major disaster that destroyed her home, ruined her possessions, forced the relocation of her family, and bankrupted her finances and then affirmed that she is feeling anxious and depressed. Calling half the population of a major metropolitan area ‘mentally disordered’ after a natural disaster based on such feelings is inconsistent with any sensible concept of mental disorder.” (p. 167)

Overall the book was very thorough and well researched, and I wholeheartedly agree that the DSM should incorporate an evolutionary approach. However, I believe that Pack Leader Psychology makes some additional connections that further explain human behavior. While anxiety is a normal reaction to fears, I do believe that people today suffer from more anxiety than they ought to. This is largely due to the fact that we our fears of social exclusion are too highly sensitized. Because we do not have strong, stable “packs” or social groups, as we did in the past, we do not have an inherent feeling of safety and social acceptance. This may have resulted because we were raised by parents who were insecure and emotionally unstable, causing us to fail to develop strong self-worth. Consequently, when we go out into the world, we search for social acceptance because we lack internal self-acceptance. A baseline of low self-worth predisposes us to anxiety, depression, personality disorders and the like.

Lots more is in “Pack Leader Psychology.” Watch for my anti-DSM essay with more on this topic as well.

Horwitz, A. V., Wakefield, J.C. (2012) “All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders” Oxford: Oxford University Press.

The Dog That Taught Me About Leadership

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Reilly, the Muse for “Pack Leader Psychology”

As I say in “Pack Leader Psychology,” a growl instantly moved me from pack member to pack leader with my dog, Reilly. But if I hadn’t had a dog that understood how to be a pack member, I might never have learned this lesson. And I might never have made the connection that being a pack leader to people might also be a good thing for my interpersonal relationships as well.

The story begins when I got Reilly as an eight-month-old dog. She had grown up in an outdoor kennel with her birth pack and several adult dogs. Living for so long with this normal dog pack taught Reilly how to recognize and honor the pack leader or leaders — probably her mother and father.

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Welcome to the inaugural Pack Leader Psychology blog post!

I’m very excited to begin this new adventure that has been about six years in the making. I have written a non-fiction self-help book called “Pack Leader Psychology,” and this blog is the first step in introducing the ideas in that book to the public. A full website will follow soon and the book is now available as an e-book on Amazon (Kindle fans!). Print and e-versions on B&N and other sites will be due shortly.

So what is the book about?  Tough to shorten 230 pages down into a few paragraphs, but here goes:

“Pack Leader Psychology” recounts the lessons I learned while becoming a pack leader to my dog, Reilly, that helped transform me from a submissive, abused wife into a calm, confident, independent and assertive human pack leader. Read More