Can you imagine doctors referring to patients as idiots, morons, or imbeciles? And, doing so not because of disliking their patients but as actual diagnostic labels?
It is difficult to conceive, but just a few decades ago the use of these particular terms was completely acceptable. Each was used to describe individuals with varying degrees of mental retardation (MR).
In my work with some older individuals with developmental disabilities, I have had the opportunity to review medical records from 50-60 years ago. (I know it’s difficult to believe, but some records that old still exist!) It is a surreal experience to see these terms used as casually as “depression” or “diabetes” is used in charts today. Yes, that’s correct, progress notes began with phrases such as, “This 18 year-old female moron,” or “This 22 year-old male imbecile.”
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Antisocial personality disorder (ASPD) and psychopathy have similarities, and there is overlap between the two diagnoses, but the diagnosis of each of the two conditions is made differently.
Before I describe these two conditions, I want to clarify the terminology further.
In psychiatric language, ASPD, or describing a patient as “antisocial,” has nothing to do with whether one socializes with other people. Of course in everyday language, the term antisocial is often used to mean just that. In psychiatry it means to go against the rules and norms of society.
Likewise, the term psychopathy is not related to the term psychosis. Psychosis refers to a break from reality. The vast majority of psychopaths are fully aware of their actions.
Antisocial personality disorder is a diagnosis described in the DSM-IV TR, the current diagnostic manual for psychiatric diagnoses. It is a diagnosis mostly reflective of a person’s behavior.
Patients diagnosed with it may exhibit any of the following: repeated acts that violate social norms (i.e., illegal activity), deceitfulness, impulsivity, aggression/irritability, repeated disregard for the safety of self or others, irresponsibility, and lack of remorse. For the sake of brevity, I am not including the full DSM description. Click here to view the full DSM-IV TR criteria.
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Recently I diagnosed a man with borderline personality disorder (BPD). As I was working with him, it dawned on me how much more comfortable I had become over the years not just in identifying BPD but in working with patients who have it and in discussing the diagnosis with them.
I recall how differently I felt about anything to do with BPD during my residency training and in my first few years of practice. Most mental health and medical professionals can attest to the fact that the term “borderline” is one of the most loaded mental health terms that exists. Unfortunately it is often used perjoratively toward hateful or challenging patients, thereby perpetuating the stigma. Probably out of my own fear, I was hesitant to bring up the diagnosis with patients. I just did not want to say the “B” word to them.
Over my career, though, I’ve realized a few things about BPD.
First, I haven’t met a person yet who
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The “bible” of psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has had a very interesting, and at times frightening, evolution. Intended to improve reliability and never intended to become a “cookbook,” the DSM has unfortunately been taken quite literally by the insurance industry, the legal system, and others.
The DSM-V is slated for release in May 2012. The original DSM was released in 1952, and the DSM II in 1968. These two early versions nearly went unnoticed and were not widely used clinically. However, the DSM III, and especially the DSM-III R, became much more recognized as providing some degree of standardization of psychiatric diagnosis.
In January 2005, The New Yorker published an article, “The Dictionary of Disorder,” which takes the reader on an interesting journey in the life of psychiatrist Robert Spitzer and his efforts to create the DSM-III and DSM III-R with the goal of improving the reliability of psychiatric diagnosis.
Spitzer assembled groups of data-oriented psychiatrists to complete the task. The problem was that
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