Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, June 26, 2014

The Subway System Ucs

In my recent post, The Core, I mentioned that I was reading a book about Antisocial Personality Disorder (ASP), Bad Boys, Bad Men, by Donald Black. I also mentioned that I had taken the book out of the library.

Well, today, as I got out of the downtown station near my office, I realized I had left the book, along with a pair of shoes, in a bag, on the train.

Yup. I lost a library book. Never happened before. In fact, I never even return a book late. And I've never left anything on the train before, either.

That's not precisely true. A couple years ago I was crocheting on my way to work, and the train jostled, and the ball of yarn fell down. I went to pick it up, but then the train stopped and jostled again, and the door opened, and the ball of yarn rolled out the door onto the tracks. And I sat there for a stop or two afterward watching my hard work unravel and get dragged away. Not my best commute.

But this is different. Oh, I can explain it away. On crowded trains, I usually put any bag I'm holding on the floor between my feet, but my back went out last week and I couldn't sit like that, so I put the bag on my lap, and then the train was slow and weird, and I had to switch to the express quickly, etc.

Can't be. Something's up. I don't know what, but I'm gonna try a little free association (minus any awkward references to toilet training or primal scenes or other stuff that really has no business on this blog).

I was planning to write a post about the book. My impressions, what I learned, what I question. I was going to include other perspectives on ASP. I had in mind the chapter entitled, Impulsive Styles: Variants, Some Psychopathic Traits, from David Shapiro's, Neurotic Styles. Maybe Freud's bit on The Exceptions. And most importantly, the sections from the Psychodynamic Diagnostic Manual (PDM): P103. Psychopathic (Antisocial) Personality Disorders, with P103.1 Passive/Parasitic and P103.2 Aggressive.

This was important to me. To introduce the PDM. I think a lot of people aren't familiar with it, but it's a great alternative to the DSM, especially when it comes to personality disorders.  It goes beyond the symptom clusters characteristic of the DSM and ICD systems (it references DSM-IV), and elaborates on the patient's internal experience of his symptoms, since it's usually a patient's subjective suffering that brings him to treatment.

I think I'll wait for another post to get into the PDM's approach. This is what I remember about the couple chapters of Bad Boys, Bad Men that I read. It's well-written and engaging. The author's intent seems to be to truly try to understand ASP, and not just derisively dismiss it as hopeless. He followed up on 30 year old cases, to try to see what happened to those diagnosed with ASP (or psychopathy) over time.
He describes these cases, and intersperses them with descriptions about well-known serial killers, or other well-knowns, like Mike Tyson. He repeatedly states that while he can't officially diagnose this one or that one as having ASP, their behavior is consistent with the diagnosis. I didn't like that. He kept saying that ASP is probably more common than is recognized, but you can't assume that just because someone behaves badly, they have ASP.
That probably sounds sensible, but it read more like he couldn't make up his mind. And I think that, in turn, was due to his extensive reliance on DSM criteria. It was all mushed together. ASP's are too impulsive to plan, yet many are capable of elaborate cons. They can't hold down long-term jobs, yet many are professionally successful.
It was all, Do they meet criteria? Some people are just born bad. They can't accept society's rules. This seemed to completely neglect an understanding of the phenomenon, well-described in the book, that these are usually people who have had terribly chaotic upbringings. If the first thing a child learns is that there are no rules, or any rules that exist don't protect him, and even harm him, why would he learn to think of rules as something desirable?
The book seemed to just go the DSM route and ignore the inner experiences of ASP's, while only examining their behavior. I'll allow for the fact that I didn't progress very far before I lost it, but while I was reading, I kept bristling at what I perceived as a lack of insight, and had to keep telling myself to wait and see how the book progressed, and maybe I'd learn something.

End of free association. And here's my analysis. I was going to say, "amateur" analysis, because I guess I still haven't gotten used to thinking of myself as an official analyst:

I don't like DSM. I REALLY don't like DSM 5. I've been trying very hard to completely ignore it, but now I'm faced with taking my board recert exam, which will require DSM stuff, which I find offensive because it's at best superficial, and at worst politically fabricated, and it's derisive towards the way I've chosen to practice my profession. It neglects what I consider to be the most important part of human existence, whether in mental illness or mental health, which is a person's internal experience of himself and the world. I was hopeful that Black's book would have a different perspective, but I was disappointed. I want to lose the DSM. I want it lost in the bowels of the NYC subway system, where maybe it can learn something about depth.

And for very complicated personal reasons, there are ways in which I identify with ASPs, even though I clearly don't live that way. So I don't want to be judged without regard to the reasons I do what I do, or feel what I feel. Not by the APA, or the ABPN, or insurance companies, or the world at large, or family or friends, or myself. Not even by the NY Public Library system, for losing one of their books.

PS: On a lighter note, please remember to enter my giveaway contest.