The article discusses, in particular, the category "personality disorders," which contains a grab-bag of "disorders" that are difficult to diagnose and treat. The problem is that not all experts agree on anything regarding these: they cannot agree even on definitions for the disorders, much less on diagnosis. In the cases of most of these "conditions" nobody has been able to show that these are "real" conditions in the way that influenza is a real disease. What, for example, is narcissistic personality disorder? Is it something with an actual existence within a person, an existence that can be demonstrated with a test (like pregnancy!), or is it just a pattern of behaviors that may or not be linked to specific causal mechanisms? To what extent are these "disorders" the result of modern society's tendency to treat certain types of behaviors as medical rather than social problems?
The current debates over this category, as well as the very history of the DSM's attempt to define various mental illnesses, make one thing very clear: the psychiatric profession, in many cases, has no idea what it is doing, largely because, in many cases, it cannot properly define the conditions that afflict those of us who seek out the profession's help. Nor, in many cases, can it even determine that these conditions are real things in the way that malaria is a real thing that can be diagnosed with reasonable certainty and then treated with therapy that actually addresses the underlying physiological mechanisms.
Why does any of this matter to dysthymics??
What we now call dysthymia was once referred to as "depressive personality personality." In 1980, with the third edition of the DSM (the DSM-III) the "disorder" was moved from personality disorder to mood/affective disorder. I tend to think of this a a positive development: it makes it easier, I believe, to see dysthymia as something that happens to us rather than something that is fundamentally wrong with us. If it is something that happens to us, we can at least look at that something as alien and perhaps treatable. Like cancer, say. Dysthymia need not be accepted as a permanent, fundamental aspect of our personalities; it is, instead, an intruder that we can fight off in order to live satisfying lives.
That, at least, is how I feel about it in my more optimistic moments. The issue then comes down to how one might go about "fighting it off." And this is where psychiatry's uncertainty is most damaging. "Dysthymia" may not be a specific "real" condition at all, or at least may not be a disease in the way that malaria is a disease. The problems with the DSM are a continuing reminder that psychiatry does not know what it is looking at; with many mental and affective disorders we are still in a stage comparable to pre-modern medicine, when doctors might decide whether a certain illness was caused by humours or by demons. And unfortunately, it is difficult to find a cure, or even treatment, when you don't even know what it is you are trying to cure or treat. But I don't want to be too pessimistic; many people are responding positively to various treatments, even if we do not know how or why those treatments work. This is no small thing. We need to carve out small victories where we can, embrace that which is not our hell.
“The inferno of the living is not something that will be; if there is one, it is what is already here, the inferno where we live every day, that we form by being together. There are two ways to escape suffering it. The first is easy for many: accept the inferno and become such a part of it that you can no longer see it. The second is risky and demands constant vigilance and apprehension: seek and learn to recognize who and what, in the midst of inferno, are not inferno, then make them endure, give them space.”
― Italo Calvino, Invisible Cities
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