As I’ve written about previously (See: Mental Illnesses, Diseases, and “Disorders”), how we currently define and classify the various mental “disorders” can sometimes create a fair degree of confusion about their underlying nature. That’s primarily because we afford labels to conditions not on the basis of what we might conjecture to be their underlying pathology but rather based solely on behaviors we can objectively and reliably observe. So, for example, when we observe that a youngster has difficulty focusing his/her attention on important tasks and sustaining attention in the midst of distracting influences, we apply the label: “Attention Deficit Disorder.” The label carries with it no inferences about why the child is attention-deficient (in fact, such a deficiency can be due to a wide variety of factors) but rather only affirms that the child does indeed have difficulty focusing. And, in our age of treating primarily symptoms as opposed to addressing underlying pathology, intervention for this kind of “disorder” most often involves providing medication that has been found to enhance attentional capacity. While these methods of labeling and intervening have some pluses, they also have some significant shortcomings (I’ll have more to say about this later in the series).
One area where I think we’re making some real headway in how we conceptualize mental disorders involves the developmental delays. As I first suggested is true of conditions like character disturbance, we have recently come to realize that many conditions, especially autism, exist along a continuum of intensity and severity. It would be nice to be able to neatly pigeon hole every developmental anomaly into a distinct syndrome, each with a known and distinct underlying pathology. After all, that would make it much easier to know how to best intervene or what we would have to look for in an eventual cure. But alas, complex creatures that we are, it’s not as simple as that. Still, the fact that we now recognize that folks who once appeared on the surface as merely as socially “odd,” shy or withdrawn may in fact have a milder form of a primarily biologically-rooted condition known to impair a person’s capacity to relate, points us in a much better direction with respect to how to help.
I’ve known many individuals who fell at very different places on the autistic spectrum. On the surface, some seemed simply highly introverted or shy. Others appeared particularly obsessive-compulsive. Still others appeared eccentric. Some even appeared puzzlingly stubborn. Many of these individuals had been given many different labels and diagnoses before it finally became clear what the underlying reason for their difficulties really was. To complicate matters even more, because every individual has a personality, and because the extent to which constitutional vs. other factors might play the larger role in shaping personality, no two “spectrum” children are exactly alike.
Several years ago, an attempt was made to distinguish children who displayed the social development delays that accompany autism but not language delays (I acknowledge this is a bit of an over-simplification) by applying the label Asperger’s Disorder. But we’ve recently dropped the disorder as an official category, recognizing that when it comes to autism, the picture is really much more complicated than that. And as we grow in our awareness of the kinds of problems that can occur in social skill development and language acquisition even for a person who is only mildly (and often unrecognized as) autistic as well as how to best intervene, many fewer youngsters are likely to experience the kinds of distress they once did in their academic and social settings.
Things get really complicated when a person with some degree of developmental delay also has some character disturbance. I’m acquainted with one case of an individual who is extremely high functioning on the autistic spectrum. And because she was gifted with very high intelligence, she was able to secure an advanced degree despite chronic social difficulties in school. Given her social skills deficits and her characteristic rigidity, working with her would have challenging enough, even in the absence of character issues. But she also just happens to be a narcissist through and through, and her haughtiness, disdain for others, insistence on always being right, etc., makes those around her want to pull their hair out at times. Given her lack of social awareness, and given the concrete nature of her thinking at times, she also can’t seem to either appreciate the dysfunctional nature of her ways or modify them. There’s a dynamic interaction between her innate tendencies and deficits and the style of relating she developed and came to prefer, and it’s a really toxic mix. It also poses a really impressive challenge for intervention. Even the experience of repeated social failures has not been enough to motivate her to seek or sincerely invest in treatment. Because she’s prone to externalize blame and to falsely assess herself, she can’t even appreciate how broken she is – not at any level of awareness. It’s a truly tragic case, especially when you consider the degree of personal failure it’s likely to take before she finds sufficient motivation to change. And even if she does find that motivation, given the nature of her other impairments, she would face an even more uphill battle than most narcissists do in making necessary course corrections.
Next week I’ll be discussing some of the more commonly diagnosed behavior and impulse-control “disorders.” And this Sunday’s Character Matters program will be specially devoted to the spirit of the season.