The First Judgment

My friend Libby is a reporter. Most recently, she's had the dubious honor of covering the Jackson trial. In the course of her investigations into the psyches of the various players in the trial, she has diagnosed as much human pathology in the past month as I have, and I'm an MD doing the night shift at a Level I trauma center. After I think about this, it makes sense: both doctors and journalists need to use their interviewing and observational skills to take a good history of the present illness. It's just a simple step to take Libby's data (in the form of her stories) and come up with spot diagnoses as we gossip over Indian food.

Psychiatry can be perversely fun that way. It's all about taking what we know about a person and fitting him into the giant puzzle of human behavior. Putting people into boxes and placing neat labels on them give us a sense of power and control; our lives may be messed up, but look at these specimens!

As a doctor, I am especially qualified to do this. But anyone can do this with help of the Diagnostic and Statistical Manual of Mental Disorders, Edition IV, known to doctors as the DSM-IV. If there is a user's manual for craziness, this is it, listing the spectrum of psychiatric disorders and providing cookbook- like checklists of the Traits That Mean You're Crazy. Think you're depressed? Well, if you have three or more of the DSM-IV criteria (including guilty thoughts, difficulty concentrating, suicidal plans, change in your eating habits, altered sleep patterns, or a feeling of hopelessness), you fit neatly into DSM-IV, category #296.2, Major Depressive Disorder.

The Jackson trial's motley crew exemplifies many traits associated with personality disorders (though one caveat is that one can have a personality trait without having a personality disorder). At the top of the pyramid of mental illness is Michael Jackson himself, the picture of narcissistic personality disorder (DSM-IV-TR #301.81), characterized by an exaggerated sense of self-importance, preoccupation with fantasies of ideal love, and sense of entitlement. Based on the description of her courtroom dramatics and stormy relationships, one can easily size the accuser's mother up based on the criteria for histrionic personality disorder (DSM-IV-TR #301-50): 1. Displays rapidly shifting and shallow expressions of emotions. Check. 2. Has a style of speech that is excessively impressionistic and lacking in detail. Check. 3. They show self dramatization, very theatrical. Check. 4. Easily influenced by others and circumstances. Check.

Libby's recent article on the Jackson groupies following the trial focuses on a particular ailment that I can't quite diagnose. I'm not sure what to make of the 19-year-old Japanese woman who idolized Jackson so much as a child that she learned English and moved to America. She still holds hope that she can someday marry her idol. This could happen, she says, because "he doesn't have Asian kids yet." The only DSM-IV category that helps me wrap my brain around this behavior is #297.1, Delusional Disorder, characterized by "the presence of irrational, false beliefs that have existed for at least one month's duration" and are not associated with medication use or schizophrenia. But this seems a bit to vague for my liking. Perhaps DSM-V will have a new category of psychoses: #597.25 - Fandom Personaltiy Disorder.

I've been avoiding talk of the (alleged) disorder that started this whole mess, but somewhat understandably, the definitions in the Sexual and Gender Identity Disorder section of DSM-IV are by far the least clear, the least incisive. While homosexuality was rightly deprived of a true DSM classification after the third revision of the classification system, the current volume has a category of "paraphilas" that includes sadism, transvestism, exhibitionism and yes, pedophilia. Interestingly, the newest version of the manual goes to great lengths to emphasize that disorder does NOT equal deviance. The label of disorder is not given because of a moral or value judgement, but because a set of characteristics causes symptoms of distress or impairment in the patients ability to function in the world.

Which begs the question, what do these DSM-IV diagnoses mean? In an ideal world, diagnoses would merely be frameworks that we would use to understand each other ("Oh, so that's why George does that.") and anticipate what others would like us to do ("Linda is depressed, so let's do this."). In reality, the DSM-IV has become a labeling tool: what you are can and will be used against you. Psychiatric disorders have an undeniable stigma and in the hands of the insecure and petty can lead to some harsh judgements. As I said earlier, putting people into boxes and placing neat labels on them give us a sense of power and control; our lives may be messed up, but look at these specimens!

I remember talking to Libby about her method of reporting these crazies. "Is it hard to not act incredulous? How do you probe for more information?"

You just have to be completely nonjudgemental, she told me. Keep a straight face, and nod, and pretend that what they're saying is the most reasonable thing in the world. When you ask them questions, just ask them, "tell me more about that". Or, "so you mean..."

Is it surpising that this is the exact same mentality that we were taught to use in medical school? Let a hint of criticsm sneak into your voice, and maybe your patient wouldn't tell you about that sexual encounter that put him at risk for HIV, or that smoking habit that would put you on the right track to diagnose his vasculitis. It's just too bad that so often we confine this attitude, this serene detatchment, to the press room and the doctor's office. What would the world be like if we lived free from fear of judgment all the time?