Friday, January 6, 2012

Diagnostics, Part 2: To View Inhaling With Suspicion

(see also: Part 1, Part 3)

This is old news (circa 2010), but I only came across it recently while trying to determine what the current view of American psychologists is about introversion. I found it astounding that, without most of us ever knowing about it, professionals in the psychology industry were proposing to use the term "introversion" as a criterion for diagnosing personality disorders.

Throughout the history of the Diagnostic and Statistical Manual of Mental Disorders (the DSM), there have been many things wrongly classified as disorders. Homosexuality, for example, once appeared as a disorder in the DSM. Now it's introversion that's being misjudged.

This is what the New York Times had to say about the matter last year (2011):

The DSM inevitably reflects cultural attitudes; it used to identify homosexuality as a disease, too. Though the DSM did not set out to pathologize shyness, it risks doing so, and has twice come close to identifying introversion as a disorder, too. (Shyness and introversion are not the same thing. Shy people fear negative judgment; introverts simply prefer quiet, minimally stimulating environments.)

In 2010, the group responsible for revising the DSM made the proposal that I mentioned above. Fortunately, there were other professionals who objected to introversion being used in such a manner. The following are two excellent letters by Hester Solomon of the IAAP, one to his own organization and the other to the DSM group, which voice his objections to this proposal in a beautiful way. Honestly beautiful.


Written by Hester Solomon
IAAP’s President Secretariat

11 May 2010

Dear Presidents and Individual Members of the IAAP

I am writing to let you know that the IAAP has made a submission to the DSM V Working Group on Personality Disorders. You may know that DSM IV (Diagnostic and Statistical Manual) is a very influential publication of the American Psychiatric Association used broadly by psychiatrists, psychologists and social workers in formulating diagnoses of mental illness and dysfunction within the community. Its influence is felt beyond the boarders of the USA, and its categorizations of mental illness have an important impact on patient diagnosis and treatment in many parts of the world.

Recently John Beebe brought to our attention that the DSM V Working Group, in its revision of DSM IV, is proposing to include the term ‘introversion’ as one of the criteria used to designate the category of ‘schizoid withdrawal’, making it one of the ‘trait domains’ indicative of personality disorder. With John’s help, we formulated a letter to the Working Group to put forward the rationale for not using the term ‘introversion’ in this way. This was forwarded to the Working Group and now appears on the APA website. The deadline for receiving such communications was 20 April 2010.

The IAAP’s response, together with this explanatory email, is being posted on the IAAP’s website in order to to keep you informed about our actions in this matter. As soon as the results of the Working Group’s deliberations are known, which may be towards the end of May, I will write again to inform you of the outcome.

I would be pleased if the Presidents of Member Groups would circulate this information to the members of their Societies.

With all my good wishes

Hester Solomon
President, IAAP

And then, even more inspiring, here's the submission to the DSM working group:

8 April 2010

Dear Dr. Skodol,

I am writing on behalf of the International Association for Analytical Psychology to urge that the term introversion not be used to identify the trait domain of personality functioning that can become, if carried to an extreme, a pathological syndrome of reclusiveness, withdrawal, and affective constriction. Introversion, a term introduced into psychiatry by C. G. Jung in 1909, has a long and varied history in personality theory, only a small part of which is captured in Theodore Millon’s otherwise extremely useful discrimination of the syndromes of personality disorder. Millon’s book, Disorders of Personality, has led many American psychiatrists and psychologists to accept the erroneous belief that introversion was simply the historical antecedent to the contemporary conception of schizoid personality disorder. Indeed, if one looks on the DSM-V website for a definition of introversion, one finds this proposed personality trait domain defined in exclusively negative terms: "Withdrawal from other people, ranging from intimate relationships to the world at large; restricted affective experience and expression; limited "hedonic capacity" with trait facets of "social withdrawal," "social detachment," "intimacy avoidance," "restricted affectivity," and "anhedonia".

This definition is transparently based on the current DSM-IV diagnostic criteria for Schizoid Personality Disorder, and thus equates introversion with a pattern that has long been regarded as personality pathology. Under the proposed new terminology, the pattern defined as introversion is a trait domain, within a dimensional approach to diagnosis. While this approach does not insist that a personality displaying the trait of introversion is ipso facto pathological, unless the trait dominates the personality to an extreme degree, the clear implication of the definition is that extraversion is the sole basis of positive affectivity and healthy relationships with others. We believe this unjustified conclusion stems from the misuse of "introversion" as a term to represent a trait domain of detachment from social relationship and one’s own affects.

For many of us, the term "introversion" means the normal and psychologically essential process of introspection and reflection through which people define, evaluate, identify, and digest both outer and inner experience. Encouraging mental health professionals evaluating personality to write and think about introversion in negative terms would be analogous to asking internists evaluating patients to view inhaling with suspicion, because it is a compromise or absence of exhaling.

The International Association for Analytical Psychology represents approximately 3000 member analysts in 50 Institutes of Jungian Analysis around the world, and their influence is sufficiently felt through teaching, supervision, publication, and, of course, clinical work, to bring us in contact with many mental health practitioners who are working closely in psychotherapy with patients who happen to be introverted. It is clear to us that patients who need to connect positively with their inner lives will suffer if the very word "introversion," which has been a lifeline to many, becomes stigmatized as it would under the proposed DSM-V wording.

I want to thank you for letting us give input as part of your own hard work to get this right.


Hester Solomon
President, IAAP

Amazing letter; few of us could have said it better. There's a lot to take in from this correspondence, but -- without question -- this is important stuff. As introverts, it seems that we should be included in such events. It would have eventually affected us in very crucial ways.

We're lucky that there are others watching out for us. Imagine what might happen to us without them!



Anonymous said...

Nice find! It's ironic too because, a while back I read an open letter of a woman describing her partner, having schizoid "personality disorder" - though she had the view that his individuality was not disordered or "pathology", just a different way of being.

I wish I could find the article again, If I find it, I will post a link. It really made an impression on me, it was also beautifully written.

Anonymous said...

Here's an interesting article;

Zeri Kyd said...

Jenna, wow, that is a wonderful paper! Thanks for sharing it; I will make sure to save it.

I thought it was interesting that the author also equates schizoid personalities with introversion (as one and the same), but that she prefers the word schizoid. She says:

Although the Jungian concept of "introversion" is perhaps a less stigmatizing term, I prefer "schizoid" because it implicitly refers to the complex intrapsychic life of the introverted individual rather than to a preference for introspection and solitary pursuits, which are more or less surface phenomena.

So reading through the paper, I found myself replacing the word "schizoid" with "introversion" in my head, translating and undoing what she'd intended to do. Although it was a pleasant change to see someone defending traits that largely deal with introversion, I still didn't agree that schizoid personalities are the same as introverted personalities.

In any case, I also enjoyed the following two quotes:

Not only does their psychology involve a kind of allergy to being the object of someone else's intrusive gaze, they have learned to fear that they will be exposed as weird or crazy.

... and ...

They may seem completely nonreactive, yet suffer an exquisite level of sensitivity. They may look affectively blunted while internally coping with what one of my schizoid friends calls "protoaffect," the experience of being frighteningly overpowered by intense emotion.

Again, thanks for the comment.

Anonymous said...


Just found the Schizoid article I was on about;

Zeri Kyd said...

Hi, Jenna! Thanks for finding that. You were determined! :-)

It's a thought-provoking letter. Above all, I think it illustrates how labels are misused and misunderstood. It's not hard to understand how the confusion would arise, though; just looking at the history of the word "schizoid" shows you how much it has changed over time. This is a good example of what happens when something natural and benign (i.e., the behavior of a "schizoid") is used to describe a disorder. The negative connotation sticks.

I thought it would be useful to track down the original description of the "schizoid" personality by Bleuler, and I found a couple of quotes online.

The first quote:

He is taciturn or has little regard for the effects on others of what he says. Sometimes he appears tense and becomes irritated by senseless provocation. He appears as insincere and indirect in communication. His behaviour is aloof and devoid of human warmth; yet he does have a rich inner-life. In this sense he is introverted. Ambivalent moods are more pronounced in the schizoid than in others, just as he distorts the meanings of, and introduces excessive doubts into, his own concepts. But on the other hand, the schizoid is also capable of pursuing his own thoughts and of following his own interests and drives, without giving enough consideration to other people and to the actual realities of life. He is autistic. The better side of this autism reveals a sturdiness of character, and inflexibility of purpose, an independence and a predisposition to creativity. The worse side of it becomes manifest in a lack of consideration for others, unsociability, a world-alien attitude, stubbornness, ego-centricity, and occasionally even cruelty.

Found in the book "Intelligence: a new look"
by Hans J├╝rgen Eysenck

And another quote by Bleuler:

Even in the less severe forms of the illness, indifference seems to be the external sign of their state; an indifference to everything -- to friends and relations, to vacation or enjoyment, to duties or rights, to good fortune or bad.

Found in the book "Disorders of Personality"
by Theodore Millon

So I think a large part of what distinguishes a schizoid personality is that indifference, particularly towards others. On it's own, I can't see why that should trouble anyone; and it's sad that it does.

PubMed, in describing the Schizoid Personality Disorder, actually goes so far as to say that such a person doesn't want or enjoy close relationships ( Though there are extremes to any behavior and personality, it's not clear to me that those extremes are necessarily bad. Nor that they should be considered disorders.

One thing I should note, though, is that the woman writing this article describes the schizoid personality as if it's synonymous with an extreme form of introversion, and I would still argue that they're not the same. Apparently, this confusion is something that is being perpetuated more and more often. The husband described in the article is probably highly introverted, and that may be among the traits that people judge harshly about him, but his introversion does not define him as having a schizoid personality. The two do not equate. Introverts, no matter how extreme (and here I speak mainly from experience), are not indifferent to others; intimacy isn't something we avoid.

Some people talk about different types of introverts, and maybe there's something to it. But I get confused when words and definitions are lumped together. I'd rather keep things simple. Language is difficult enough.

In any case, the article is moving. It makes me wonder what would happen if a new disorder was created -- for instance, one called "Introversion Personality Disorder". It's frightening to think about.

Thanks again for the link.

Anonymous said...

I have nothing really to build upon what you have said, as simply, what you have said makes perfect sense!

Thanks for taking the time to look more deeply into the article.

Its funny, when I read the article back to myself, I wondered why I had felt so moved, or thought the article was so "beautifully written". Not to negate what was written, just makes you aware the effect of ones imagination coloring descriptions, and meaning... yet I still love the article. Maybe I was emoting at the time in a certain way, which made me feel a certain empathy etc... Anyway, thanks again. :)

Zeri Kyd said...

Jenna, you're welcome, and I understand. Some things can strike a chord given the right mood.

(Hm, just noticed my spelling errors above. :-) Wish Google allowed me to edit my comments.)