Psychopathy and the DSM

The fight between reality and an insurance reimbursement manual

Psychopathy was categorized under ASPD in the DSM, and for some reason, because that happened, it has become hopelessly entangled with it. So much so that there are people, unfortunately, many people, that make the claim that because it is not in the DSM, it doesn’t exist.

The DSM is an insurance repayment manual. It is not a bible, but that doesn’t change the fact that many people are unwilling to hear that information, and place the DSM into a proper place of consideration. It is a bit like taking the Medicare Claims Processing Manual and stating, if something isn’t in it, it doesn’t exist. Lots of things aren’t in manuals like that. If the insurance company doesn’t recognize it as something that they reimburse, it won’t be in there for you to nab a code on it. It doesn’t change the fact that whatever it is you are seeing the doctor for exists.

However, people like to make this blanket statement about the DSM, they place it in a higher position of authority that it most definitely does not deserve. Even worse than that is how it is decided that things make it into the DSM, or do not.

The DSM is actually compiled by a group of clinicians that meet and discuss what will and won’t be included in the next edition. One person isn’t the deciding factor, they haven’t that kind of power. And in fact, the main person that might be considered as the factor of discluding psychopathy would be Lee Robins, a sociologist.

Why have these things all been lumped together? Well, there is an interesting history lesson to be had in the creation of the DSM. This was well described in the book by Jon Ronson, The Psychopath Test.

In it, he talks about the original DSM only being sixty-five pages. A small drop in the bucket compared to the 947-page monster the DSM-V has become. The original was used for state hospital statistical reporting reasoning, not as an important research tool.

Psychiatrist Robert Spitzer, who was responsible for the lobbying against, and subsequent removal of homosexuality as a mental condition from the DSM gave him the opportunity to be on the editing team for the DSM-III. Spitzer was irritated with the overall handling of psychiatry. He found the diagnostic process to be inefficient, and respected people like Robert Hare, who had taken Hervey Cleckley’s psychopathy checklist, edited it slightly, and rebranded it as his own. Spitzer thought that it was a far better choice to have checklists that psychiatrists could go through and know if a patient had a disorder.

For the next six years over a collection of meetings with the rest of the editing team, the DSM-III took form. This was done in a way that then appeared to be rather pragmatic, and now appears to be rather cavalier. The group of clinicians would throw out names of proposed conditions, like PTSD, ADD, BPD, and then the traits that in their minds defined these conditions. The reasoning for this was that this would eradicate the guesswork. A clinician could pick up this “bible” of disorders, find the proper checklist and help the patient sitting before them. Sounds wonderfully scientific. At least it did to them at the time.

This is also how nearly every single mental condition that most people know of was decided on, the overt traits that define it, and the treatment plans that ended up arising out of it.

So, now we fast forward to the DSM-V and psychopathy. Robert Hare went toe to toe with a sociologist Lee Robins. Robins contended that empathy was not something that could be quantified by a doctor. That it was too subjective and that sticking to the overt traits that had been decided on for the ASPD definition was what should be all that is offered. The editing team agreed with Robins, and psychopathy was therefore lumped under the ASPD diagnosis, much to Robert Hare’s enraged chagrin.

So, it is because of an arbitrary assignment of traits that a group of people decided on themselves in a room that turns into the mental disorders that we all know so well. If your symptoms do not match, you are out of luck, it’s not on the list. I often think of people that have conditions that don’t precisely fit the checklists to be standing outside the very hot nightclub wanting to go in and get the privileges that those that do fit get, like treatment, financial help, validation. You can’t get any of those things because the DSM is the bouncer, and you’re not on the list. Sorry.

This is what people are giving so much power to. This is what people are allowing to decide what deserves recognition, and what does not. It seems like anyone with two brain cells to rub together wouldn’t think that this was a reasonable method at all, but this is the one that is used. More clinicians need to be clear about what the DSM is, but that poses a problem. A lot of clinicians rely on it to do the work for them. They are looking at you and whatever problem you are presenting with, and are going down all the checklists that they are familiar with. Which one do you fit?

You can find evidence of this in the rash of diagnoses that will occur from time to time. ADHD, Bipolar, to name a couple, there was a time when each of these was in the forefront of diagnosticians’ minds, and these labels were handed out like candy. I am not saying that they don’t exist, or that if you have one of them, that you don’t actually have it, but ADHD was given out so frequently that there was a whole generation of children that were given Ritalin like it was nothing. Now we find out that Ritalin has significant effects on brain development and shouldn’t be given to children. No one even bothered to consider that in the past, and now a mess is left behind.

My point with this article is to question when people say things with definitely, like, psychopathy is not in the DSM, therefore it doesn’t exist. Asperger’s isn’t in there either, but tons of research studies are specifically done on Asperger’s, not “high functioning autism”, just like psychopathy isn’t in there, but there are many studies done on it. It’s amazing that the researchers can get funding for nonexistent things.

The next couple of entries will be about psychopathy, and the separation between it, and ASPD. It is a confusing arena to tread in, and there is a lot of very misleading information out there. I will do my best to clarify things, and give you the links to do your own research.

The Psychopath Test