Psychiatric Name Calling

by | Feb 11, 2016 | General Articles, Psychology

Psychopath, narcissist, borderline, etc.

Psychiatric nomenclature, revised recently for the fifth or sixth time, does a poor job of defining disease. The problem is that most serious psychiatric illnesses, such as schizophrenia or manic-depressive illness have no unequivocally specific signs or symptoms, let alone causes. Many of the behaviors they encompass overlap. The fact is, we do not know enough about these conditions to define them accurately. Each one probably represents a number of different biological states determined by different genetic factors and other specific biological pathways that have not yet been delineated. Currently, all of psychiatric diagnosis is largely descriptive. Which is okay, as far as it goes. It is important that when a clinician uses a diagnostic label, other clinicians have some idea of what he is talking about. If a term is vague, it is understood to be vague.

So, one way of understanding this problem is to think of psychiatric terms as unlikely to be valid, in the sense that they are actually describing something specific and real. Yet, oddly, they are more or less reliable, in the sense that different people will understand the terms in the same way. Some terms have even less significance.

The history of “Borderline Personality” demonstrates some of these problems. It was used originally to describe certain behaviors which seemed to reflect something worse than a neurosis but not as severe as a psychosis. They were “borderline” between these states. Current at that time, but no longer in use, was the term “pseudoneurotic schizophrenia,” which meant something similar. “Borderline” meant different things to different researchers for a long while until a consensus developed. That definition can be found now in the DSM-5. Changes in nomenclature have not stopped. I have heard certain patients spoken of as “Borderline Borderline.” The problem is that people, finding that a certain set of symptoms and behaviors has a name, start to think of that syndrome as a thing, such as tuberculosis or rheumatoid arthritis. It is not one thing. The DSM-5 lists nine criteria for making the diagnosis of Borderline. Someone who feels bad and who behaves in certain self-destructive and impulsive ways is likely to be called a Borderline.

But “Borderlines” can and do lose their symptoms, in which case they are no longer Borderline. Usually, then they can be slotted into some other diagnostic category. One difficulty is that “borderlines” are given treatments which are quite general but which are thought to be specific to that condition. Another difficulty is that clinicians learn to expect certain behaviors from Borderlines, which tends to reinforce those behaviors, such as suicide attempts and drug use.

All of this is somewhat tangential to the point I want to make. Since these terms are vague, they can be tossed around to condemn rather than to understand. Some of these diagnostic labels are purely pejorative. Often, when they are used, even by clinicians, they mean simply that the speaker does not like or approve of the person being labelled. They are insults and should not be understood to reflect anything real. I mention some of these terms below:

Terms listed in the DSM-5 to describe certain personality disorders. I offer the definition that most people use:

Paranoid Personality—someone who is annoying because he/she is suspicious of your motivation or, maybe, the motivations of people you know.

Antisocial Personality—someone who stays home a lot or, at least, is not interested in partying.

Histrionic Personality—someone who makes a fuss over everything

Narcissistic Personality—someone who is not concerned very much about your feelings. Self-centered is usually a better term. (A psychoanalyst once told me that homosexuality was an expression of narcissism. In this context the word means nothing at all.)

Other terms in current use:

Hypochondriac—someone who worries a lot about health, and complains too much.

Nymphomaniac—someone you think is having too much sex with too many people. A woman.

Masochist—someone who gets into one bad relationship after another.

Other terms which once seemed to mean something specific, but are falling out of professional use:

Psychopath/sociopath—someone who has lied to you on more than one occasion without seeming very remorceful. Perhaps someone who steals.

Moron/imbecile/idiot—all technical terms which were once defined clearly. Now they refer to someone who is stupid or who has said or done something stupid.

These terms may have some residual meaning to mental health professionals, but not much. Even when used by a psychiatrist, they mean principally that the psychiatrist does not approve of that person. With the exception of “hypochondriac,” a term which can be used in a systematic way, I have never had occasion to describe anyone with any of the terms used above. If someone is behaving in a reprehensible manner, I think any condemnation should be explicit about that behavior and not hint at some more fundamental mental disorder. Ordinary language does fine. At least, when you call someone crazy, you are not pretending to speak with special psychological understanding. (c) Fredric Neuman. Author of “Caring.”