November 28th, 2015

Possible refactoring of psychological disorders

For people unfamiliar with the concept of refactoring, this is the one I'm thinking of:

"Refactoring is usually motivated by noticing a code smell.[2] For example the method at hand may be very long, or it may be a near duplicate of another nearby method. Once recognized, such problems can be addressed by refactoring the source code, or transforming it into a new form that behaves the same as before but that no longer "smells". For a long routine, one or more smaller subroutines can be extracted; or for duplicate routines, the duplication can be removed and replaced with one shared function. Failure to perform refactoring can result in accumulating technical debt; on the other hand, refactoring is one of the primary means of repaying technical debt."

The basic idea is simple. If a body of code contains basically the same functionality in more than one location, it is harder to maintain. If the same functionality must be changed, the change must be made in all the locations, rather than just one. Also, more code means more to remember and understand.

In the course of reading _Neurotribes_, I learned that one of the original perpetrators of the DSM, Adolf Meyer, wasn't really interested in resolving the disputes between then-extant forms of psychoanalysis, and thus the DSM was a sort of catholic (with a small c) document intending to capture multiple ways of thinking about a disorder, a handbook usable by all practitioners using one of the common modes of analysis.

Obviously, Meyer's approach helped validate and apply a first cut of consistency to diagnosis in a nascent field. However, Meyer's approach _also_ lent itself to an octopus-like field of competing theories of the same presenting cluster of symptoms, usually the result of focusing on different aspects of the Problem: is the presentation thought of from a relationship perspective, an individual perspective, a member of a family perspective, is it thought of as having a biological component, as a result of a developmental process, as an adaptation, etc.

Basically, this fucker is _ripe_ for refactoring.

I tend to dislike psychological diagnoses in general, because I think they are creaky, large and pointless structures that do not suggest a solution that a Real Life Person or their compadres in life might view as Helpful. In the interests of coming up with a small, identifiable and measurable Thing that can be adjusted, I think of our psychological makeup as being an assemblage of modules. But while I really want to get into that, I'm not going to do that right now, because I Noticed Something Interesting. See, I _want_ to refactor the whole DSM to reflect my theory of modules, mostly for my own personal interest and to get it all neatly organized in my brain.

Right at the moment, however, I cannot help but notice a startling similarity between Somatoform Disorder and Borderline Personality Disorder. You may know the former as Munchausen's, and you may be more familiar with the much more Outrage Inducing Newsworthy cases of Munchausen's Syndrome by Proxy, in which someone gets lots of attention by making it look like their kid has a whole lot of stuff needing medical attention but it is all a big ole fake.

Backing up a ways, Somatoform is where all that psychological paralysis and psychological hearing loss, and a host of other things that showed up on "House" over the years wound up in a bin together: you _look_ like you have some Serious Thing and you're really freaked out about it, and you probably really _do_ feel those feelings (like thinking you are pregnant when you aren't), and for most purposes those seizures are real they just persistently refuse to show up on an EEG -- generally there's no medical evidence for what you have and this kind of thing has been happening on and off since before you were 30. Somatoform is difficult to treat.

The refactor I'm proposing is: Borderline Personality Disorder is Somatoform disorder, only it is focused on the medical health profession, specifically.

Now, before you go, like you know anything about any of this, check this out:

I am not the first person to think of this. (Conversion disorder is a subset of somatoform and DBT is the only evidence based treatment for BPD.)

Before that, on page 99 of: The Mind-Body Interface in Somatization: When Symptom Becomes Disease, by Lynn W. Smith, Patrick W. Conway, the authors note that there's a lot of personality disorder comorbidity with somatoform disorders, they share some developmental factors (history of physical and sexual abuse, presumably, but probably also chronically critical and hostile childhood environment and a lack of a safe caretaking relationship), and people with somatoform disorders have the same ego deficits (unstable and/or fragmented sense of self, identity subject to radical, rapid changes) that are targeted by the skill building of DBT. When that book was published (2009), they couldn't find anyone trying this, but they think it's worth a shot.

Why have I not heard of this before? ACT edition

In this case, I refer to this:

I was looking at books by Linehan or where she was listed as an editor/co-author. Several comments referred to ACT, and I went, what the heck is that? Basically, if you take the Milton Erickson -> Bandler and Grinder -> wtfery, rip out Erickson's Let's Make Everyone a Member of a Heteronormative Family and, instead of leaving a total absence of values, insert a sort of Buddhist thing, you'd get ACT. Language oriented observation that a lot of people are busy avoiding/suppressing/trying to destroy their internal convo and that has bad effects. Their internal convo is quite painful, and they need help tolerating it. Unlike other CBT approaches, there is no assumption of underlying health, nor is there a goal of "control".

Seems pretty amazing. I am very excited to learn more! Anyone run across anyone involved in this as a clinician, patient, family member or friend assisted by the approach, etc.?