'Oppositional defiant disorder' ... really?

Many people unfamiliar with psychiatric diagnostic practices are surprised to learn that the DSM-5 includes a diagnosis of 'oppositional defiant disorder'. This diagnosis, used with children, is defined by 'a pattern of negativistic, hostile, and defiant behaviour lasting at least 6 months'. The specific diagnostic criteria include: actively defying or refusing to comply with adults' requests or rules, deliberately annoying people, blaming other people for his or her mistakes or misbehaviour and being angry and resentful. If you believe DSM-5 (I don't), these can be grouped into three types: angry/irritable mood, argumentative/ defiant behaviour, and vindictiveness.

Children can sometimes be painfully unhappy. And children can sometimes be entirely unresponsive to their parents, or, indeed to other authority figures. I certainly would not want to imply that such problems don't exist or that they are trivial. I just don't think they are 'illnesses'. I am - to be clear - absolutely convinced that children and young people can be negativistic. They can be hostile. They can actively refuse to comply with adults' requests or rules. I have to say, these kinds of problems are often indications that the child has experienced some significant trauma. But in any case, I do not wish to make light of real, painful, problems. These kinds of difficulties can have terrible consequences for children and their parents. But I simply don't think it's sensible, useful, scientifically appropriate or clinically justifiable to suggest that the children have a 'disorder'. Apart from anything else, this kind of labelling makes people think that these problems are not really normal human problems at all, but instead are 'symptoms of mental illness'. I don't like it when my children are defiant or refuse to comply with my requests. But I don't think they are mentally ill.

Another example of the problems with the idea of 'mental illnesses' is the contentious issue of 'personality disorder'. 'Personality disorders' are defined as 'long-standing patterns of maladaptive behaviour that constitute immature and inappropriate ways of coping with stress or solving problems'. It is fascinating and horrible how a person's whole character can be rendered into a 'disorder'. Examples of personality disorder include; 'antisocial personality disorder', 'paranoid personality disorder', 'narcissistic personality disorder', 'schizoid personality disorder' etc. Antisocial personality disorder is particularly interesting in the context of the validity of diagnoses of mental disorder, because it illustrates the weird circularity of these ideas. Do people do bad things because they are suffering from 'antisocial personality disorder' or do they get labelled with 'antisocial personality disorder' because they do bad things?

'Personality disorders' are interesting in part because the authors of diagnostic manuals seem to be entirely undecided as to how many of these 'disorders' there are - DSM-5 and ICD-10 do not agree. Discussions and debates frequently occur as to whether 'personality disorders' could be entirely expunged from the diagnostic manuals (replaced, perhaps, with a description of personality traits). So they appear to have a fleeting, ghost-like reality - written into existence; potentially deleted - as the committees deliberate. But, despite their oddity, their circularity, their tenuous claimed validity, it can be significant if you receive a diagnosis of 'personality disorder'. The UK Government linked an entire offender management programme - the Dangerous and Severe Personality Disorder programme, designed to help manage very seriously dangerous offenders - to the concept.

 
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